BOOKS  BY 

EDWARD  P.  DAVIS,  M.  D. 


Operative  Obstetrics 

Octavo  of  483  pages,  with  264  illus- 
trations. Cloth,  $5.50  net;  Half 
Morocco,  $7-QO  net- 


of  Obstetrics 

i2mo  of  463  pages,  with  171  illus- 
trations. Just  Out. 


Obstetric  and  Gynecologic  Nursing 

I2mo  of  480  pages,  with  97  illustra- 
tions.    Buckram,    $1.75   net. 
Fourth  Edition. 


MANUAL 

OF 


OBSTETRICS 


EDWARD  P.  DAVIS,  A.  M.,  M.  D. 

PROFESSOR  OP  OBSTETRICS  IN  THE  JEFFERSON  MEDICAL  COLLEGE 
PHILADELPHIA 


WITH  171  ILLUSTRATIONS 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1914 


\ 


Copyright,  1914,  by  W.  B.  Saunders  Company 


PRINTED     IN    AMERICA 

PRESS    OF 

W,    B.    8AUNDERS    COMPANY 
PHILADELPHIA 


PREFACE 


THIS  book  has  been  made  to  give  a  concise  account  of 
modern  obstetrics.  So  rapid  is  the  growth  of  modern  knowl- 
edge that  one  who  wishes  to  study  the  newest  gains  in  obstet- 
ric science  must  consult  the  best  journals  throughout  the 
world.  It  is  the  hope  of  the  writer  that  this  book  may  help 
the  general  practitioner  and  the  medical  student  to  study 
obstetric  diagnosis  from  the  clinical  standpoint,  and  to  learn 
how  to  make  wise  decisions  in  treatment. 

EDWARD  P.  DAVIS. 

PHILADELPHIA,  PA., 

250  SOUTH  TWENTY-FIRST  STREET 

September,  1914 


11 


CONTENTS 

PAGE 

DEFINITION 17 

CHAPTER 

PART   I— ANATOMY  AND  PHYSIOLOGY 

I.  THE  ANATOMY  OF  THE  NORMAL  BONY  PEI/VIS 19 

II.  THE  ANATOMY  OF  THE  ABNORMAL  BONY  PELVIS 29 

III.  PHYSIOLOGY  OF  IMPREGNATION 39 

IV.  THE  ANATOMY  OF  THE  BIRTH  CANAL  IN  PREGNANCY 42 

V.  THE  GROWTH  AND  DEVELOPMENT  OF  THE  EMBRYO 50 

PART   II— PREGNANCY 
VI.  PREGNANCY 65 

VII.  THE  DIAGNOSIS  OF  PREGNANCY 69 

History  of  Pregnancy 69 

Physical  Examination 71 

Pelvic  Examination 72 

Diagnosis  of  Later  Pregnancy 74 

Recognition  of  Positions  and  Presentations 78 

Fetal  Movements 79 

Auscultation 79 

Measurement  of  the  Pelvis 81 

Position  of  the  Placenta 87 

Differential  Diagnosis  of  Pregnancy 88 

Diagnosis  of  Pregnancy  by  X-ray 92 

VIII.  THB  PHYSIOLOGY  OF  PREGNANCY 93 

IX.  THE  HYGIENE  OF  PREGNANCY 98 

X.  THE  MATERNAL  AND  FETAL  PATHOLOGY  OF  PREGNANCY  .  .  103 

The  Toxemia  of  Pregnancy 103 

The  Toxemia  of  Later  Pregnancy Ill 

Fetal  Toxemia  in  Later  Pregnancy. 116 

Infectious  Diseases  Complicating  Pregnancy 119 

The  Fetus  in  Acute  Infectious  Diseases 126 

Chronic  Diseases,  Poisoning,  and  Accidents  Com- 
plicating Pregnancy 128 

Abnormal  Conditions  of  the  Pelvic  Organs  Compli- 
cating Pregnancy 133 

Abortion 142 

13 


14  CONTENTS 

CHAPTER  PAGE 

PART   III— LABOR 

XI.  THE  CAUSES  AND  TREATMENT  OF  LABOR 150 

The  Mechanism  of  Labor 151 

Vertex  Presentation 151 

Face  Presentation 157 

Breech  Presentation 160 

XII.  THE  PHYSIOLOGY  OF  LABOR 168 

XIII.  THE  CONDUCT  OF  LABOR 173 

XIV.  THE  PATHOLOGY  OF  LABOR 186 

Posterior  Rotation  of  the  Occiput 186 

Presentation  of  the  Parietal  Bone 191 

Brow  Presentation 193 

Posterior  Rotation  of  Chin 194 

Transverse  Position  of  the  Head 195 

Transverse  Position  of  the  Fetus;  Shoulder  Presen- 
tation    197 

Impaction  of  Twins 202 

Posterior  Rotation  of  the  Trunk 203 

Impaction  of  the  Shoulders 211 

Prolonged  Labor 211 

Uterine  Inertia 211 

Disproportion  Causing  Prolonged  Labor 217 

Impaction  of  the  Fetus 220 

Rupture  of  the  Uterus 221 

Prolapse  of  the  Cord  or  Fetal  Parts 226 

Infection  Complicating  Labor 228 

Sudden  Death  in  Labor 230 

Ectopic  Pregnancy 232 

Placenta  Prsevia 240 

Multiple  Pregnancy 252 

Hemorrhage 256 

Septic  Infection 272 

PART   IV— THE  NORMAL  PUERPERAL  PERIOD 

XV.  THE  MOTHER 291 

Involution 291 

Lochial  Discharge 292 

Involution  of  the  Genital  Tract  Aside  from  the 

Uterus 294 

Return  of  Patient  to  Normal  Condition 295 

The  Urine  During  the  Puerperal  Periotl 296 

Lactation 297 

XVI.  THE  CARE  OF  THE  NORMAL  IXFANT  DURING  THE  MOTH- 
ER'S PUERPERAL  PERIOD 303 

XVII.  OBSTETRIC  ASEPSIS  AND  ANTISEPSIS 307 

PART  V— OBSTETRIC  OPERATIONS   (OBSTETRIC 
SURGERY) 

XVIII.  THE  FORCEPS 323 

XIX.  VERSION  .  .  .343 


CONTENTS  15 

CHAPTER  PAGE 

XX.  EMBRYOTOMY 358 

XXI.  PREVENTION  AND  CLOSURE  OF  LACERATIONS 365 

XXII.  INJURY  TO  THE  BONY  PELVIS  OCCURRING  DURING  LABOR  372 

XXIII.  THE  INDUCTION  OF  LABOR 373 

XXIV.  CESAREAN  SECTION 381 

Abdominal  Cesarean  Section 381 

Extraperitoneal  Section 386 

XXV.  ENLARGEMENT  OF  THE  PELVIS 400 

Symphysiotomy 400 

Pubiotomy 403 

Enlargement  of  the  Pelvis  by  Lessening  the  Size  of 

the  Promontory  of  the  Sacrum 405 

XXVI.  RUPTURE  OF  THE  UTERUS 408 

PART  VI— THE   FETUS 

XXVII.  FETAL  PATHOLOGY 414 

XXVIII.  INJURIES  TO  THE  FETUS  IN  LABOR 428 

XXIX.  MIXED  FEEDING 441 

XXX.  THE  MEDICO-LEGAL  ASPECTS  OF  OBSTETRIC  PRACTICE  . .  444 

INDEX. .  .  453 


MANUAL  OF  OBSTETRICS 


DEFINITION 

Obstetrics  is  the  science  of  human  reproduction.  A  similar 
study  in  warm-blooded  animals  other  than  human  is  em- 
braced in  veterinary  medicine.  The  word  "obstetrics"  is 
supposed  to  convey  the  idea  that  the  obstetrician  or  mid- 
wife aids  the  mother  during  parturition,  performing  a  func- 
tion which  is  confidential  in  the  interests  of  both  husband 
and  wife. 

Early  obstetric  science  was  the  practice  of  midwives,  and 
hence  the  name  obstetrics  does  not  occur  during  this  period, 
but  the  treatment  of  human  parturition  was  known  as  mid- 
wifery. When  men  began  to  study  obstetric  art  and 
science,  the  modern  science  had  its  beginnings  and  persisted 
in  a  crude  state  until  the  discovery  of  asepsis  and  antisepsis, 
and  the  revolution  in  surgery  which  followed.  This  brought 
obstetrics  into  the  domain  of  surgery  as  a  science. 

Modern  obstetric  science  embraces  the  diagnosis  of 
pregnancy  in  its  various  stages,  a  knowledge  of  the  anatomy 
of  the  birth  canal  in  the  pregnant  woman,  the  hygiene  and 
pathology  of  the  mother  during  pregnancy,  and  of  the  fetus 
as  well.  The  mechanism,  physiology  and  treatment  of  labor 
and  its  complications,  form  an  important  part  of  obstetric 
science. 

The  aseptic  care  of  the  mother  during  parturition  and  the 
repair  of  lacerations,  introduces  obstetric  surgery.  The 
nerformance  of  the  operations  necessary  to  save  the  lives  of 
mother  and  child  opens  the  way  for  obstetric  surgery,  and 
many  of  the  injuries  of  the  newborn  require  surgical  atten- 
tion. The  complete  restoration  of  the  mother  to  health 
renders  necessary  the  late  performance  of  operations  for  the 
repair  of  injuries. 

17 


18  MANUAL   OF   OBSTETRICS 

The  most  serious  complications  of  pregnancy  demand 
surgical  attention,  as  in  placenta  prsevia  and  accidental 
placental  separation.  In  the  important  and  complex  condi- 
tion known  as  the  toxemia  of  pregnancy,  a  wide  range  of 
medical  and  surgical  knowledge  is  essential  to  secure  the  best 
results. 

Many  unsolved  problems  of  great  importance  remain  in 
obstetric  science.  The  causes  of  eclampsia  are  yet  unknown, 
and  there  is  still  question  concerning  the  best  means  of  pre- 
venting this  serious  accident.  Conditions  which  sometimes 
destroy  the  fetus  are  not  completely  understood,  and  much 
is  still  to  be  learned  in  the  saving  of  infant  life. 

Modern  obstetric  science  embraces  a  considerable  field  of 
anatomy,  physiology,  pathology  and  surgery.  The  respon- 
sibility of  the  obstetrician  is  great,  as  two  lives  are  in  his 
care.  To-day,  advances  in  obstetric  surgery  have  been  made, 
with  greatly  reduced  mortality  and  morbidity,  which  enable 
the  obstetrician  to  deal  with  serious  problems  satisfactorily. 


PART    I 
ANATOMY  AND    PHYSIOLOGY 


CHAPTER  I 
THE  ANATOMY  OF  THE  NORMAL  BONY  PELVIS 

The  bony  pelvis,  as  a  whole,  is  situated  at  the  termination 
of  the  spinal  column  and  affords  articulation  for  the  lower 
extremities.  It  is  a  bony  basin  or  girdle,  composed  of  indi- 
vidual parts  bound  together  by  ligaments.  In  previous 


Fig.  1. — Normal  female  pelvis. 

stages  of  evolution,  when  the  human  being  assumed  the  up- 
right posture  less  constantly  than  now,  an  important  function 
of  the  pelvis  was  to  contain  the  organs  of  generation  and  to 
shelter  the  growing  embryo  until  the  increasing  size  of  the 

19 


20  MANUAL   OF   OBSTETRICS 

womb  encroached  upon  the  abdominal  cavity.  As  human 
beings  stand  habitually  upright  the  pelvis  has  given  greater 
support  to  the  head  and  trunk.  Its  individual  bones  are 
the  sacrum,  the  two  innominate  bones,  each  composed  of  the 
ilium,  the  ischium,  and  the  pubes,  and  in  addition  the  termina- 
tion of  the  spinal  column  in  the  coccyx. 

The  Sacrum. — This  bone  is  composed  of  vertebrae  joined 
together,  the  bone  being  concave,  projecting  backward,  its 
upper  portion  marking  the  projection  known  as  the  promon- 
tory of  the  sacrum.  As  the  bone  is  broader  along  the 
anterior  surface  than  on  the  posterior  surface,  with  the  indi- 
vidual in  the  upright  position,  it  would  fall  downward  and 
forward  were  it  not  bound  firmly  to  the  two  innominate 
bones  by  the  sacro-iliac  ligaments.  The  sacrum  is  the  most 
important  bone  in  the  pelvis,  as  it  is  the  most  fixed  point  in 
the  pelvis  upon  which  the  two  lateral  halves  rotate  during 
parturition  in  young  persons.  Its  promontory  lessens  the 
space  at  the  entrance  to  the  pelvis  from  above,  and  makes 
what  is  called  the  superior  or  upper  strait  of  the  pelvis.  The 
posterior  surface  of  the  sacrum  contains  the  termination  of 
the  spinal  canal  and  the  end  of  the  spinal  cord.  The  sacrum 
is  not  only  the  largest,  but  the  heaviest  and  strongest  bone 
in  the  pelvis. 

The  Ilia. — The  ilia  are  the  upper  portions  of  the  innominate 
bones  and  are  peculiar  for  a  projecting  wing  which  forms  the 
iliac  fossa  on  each  side  and  constitutes  the  greater  portion 
of  the  upper  pelvis,  or  what  is  sometimes  called  the  false 
pelvis.  The  crests  of  the  ilia  are  broad  and  rough,  giving 
origin  and  insertion  to  the  abdominal  muscles,  while  in  the 
iliac  fossae  lie  the  ilio-psoas  muscles  which  extend  along  the 
pregnant  pelvis  on  each  side.  On  the  anterior  surface  of 
each  ilium  at  the  anterior  extremity  of  its  crest  is  a  bony 
landmark,  the  anterior  superior  spine  of  the  ilium,  which 
can  be  detected  in  all  individuals,  and  is  a  bony  landmark  on 
measuring  the  pelvis.  At  the  posterior  extremity  of  the 
iliac  crests  are  the  posterior  superior  spines,  also  landmarks 
for  measurement.  The  ilia  terminate  at  their  junction  with 
the  sacrum  in  an  irregularly  roughened  joint  surface  contain- 
ing a  synovial  membrane,  these  surfaces  being  firmly  bound 
together  by  strong  bands  of  ligament  on  the  posterior  surface, 


ANATOMY   OF   NORMAL   BONY    PELVIS  21 

known  as  the  sacro-iliac  ligaments.  The  contour  of  the  ilia 
varies  somewhat  in  different  races,  and  is  an  essential  char- 
acteristic in  the  normal  pelvis.  At  the  lower  external  portion 
of  the  ilia  are  the  acetabular  cavities  which  receive  the  heads 
of  the  femora.  The  inner  portion  of  the  ilium  terminates 
in  a  distinct  curved  surface,  known  as  the  pelvic  brim  or 
linea  terminalis.  This  curve  is  continued  along  the  pubes  to 
the  anterior  portion  of  the  pelvis  at  the  pubic  joint. 

The  Ischia. — Beneath  the  acetabular  cavity  is  a  strong, 
irregularly  circular  bone  with  a  foramen,  the  lower  extremity 
being  slightly  curved,  broad,  and  a  bony  landmark  called 
the  tuberosity  of  the  ischia,  upon  which  rest  the  greater  part 
of  the  weight  of  the  body  in  the  sitting  posture.  The  fora- 
mina serve  to  permit  the  passage  of  vessels  and  nerves  from 
the  interior  of  the  pelvis  to  the  lower  extremities.  On  the 
internal  surface  of  each  ischium  is  a  projecting  ridge  directed 
upward  and  inward,  which  can  be  felt  by  vaginal  examina- 
tion, and  which  is  called  the  spine  of  the  ischium.  Like  the 
promontory  of  the  sacrum,  it  encroaches  somewhat  upon  the 
space  at  the  lower  part  of  the  pelvic  cavity. 

The  Pubes. — The  upper  rim  of  the  anterior  pelvis  is  com- 
posed of  the  two  pubic  bones.  Their  upper  branches  are 
known  as  rami  of  the  pubes,  terminating  at  the  centre  in  a 
projection  which  can  usually  be  felt  through  the  external 
skin  by  making  pressure  over  the  pubic  joint.  The  two 
pubic  bones  terminate  in  the  symphysis  pubis,  composed  of 
cartilage,  the  bones  being  firmly  fastened  by  two  strong 
bands  of  ligament  above  and  below.  Like  the  sacro-iliac 
joints,  the  pubis  is  an  articulation,  and  during  pregnancy  the 
two  pubic  bones  move  upon  each  other  through  the  elasticity 
of  the  joint. 

The  Coccyx. — While  the  sacrum  is  thick,  comparatively 
heavy,  and  contains  four  foramina  for  the  exit  of  nerves,  the 
coccyx  is  composed  of  four  vertebrae,  diminishing  in  size,  and 
contains  no  openings.  It  is  the  vestige  of  the  tail  and  was 
more  highly  developed  in  a  previous  state  of  evolution.  It 
is  joined  to  the  sacrum  by  ligamentous  fibres  with  a  joint 
which  permits  it  to  move  upon  the  sacrum. 

The  Upper  or  False  Pelvis. — By  the  upper  or  false  pelvis 
is  meant  the  expanded  wings  of  the  ilia  which  lie  above  the 


22  MANUAL   OF   OBSTETRICS 

true  pelvic  brim.  The  abdominal  and  back  muscles  are 
attached  to  the  upper  pelvis  and  the  expanded  termination 
of  the  abdominal  cavity  is  formed,  in  which  are  contained 
the  intestines  in  the  non-pregnant  patient,  and  upon  which 
during  pregnancy  often  rests  the  enlarged  uterus.  It  has  no 
function  in  labor  and  is  rarely  of  importance  in  obstetric  study, 
except  for  the  fact  that  the  ilia  present  bony  landmarks  for 
measurement  and  the  important  sacro-iliac  joints. 

The  True  or  Lower  Pelvis. — As  the  fetus  must  pass  through 
this  cavity,  it  is  of  great  importance  to  the  obstetrician.  In 
the  centre  posteriorly  is  the  sacrum  with  its  projecting 
promontory  and  its  backward  curve  beneath  the  promontory. 
From  the  sacro-iliac  joints  to  the  pubis  on  each  side  runs  the 
linea  terminalis,  or  iliac  line  or  pelvic  brim.  In  the  normal 
pelvis  this  is  essentially  a  regular  curve,  terminating  ante- 
riorly in  the  pubic  joint.  It  is  obvious  that  at  the  pelvic 
brim  the  promontory  of  the  sacrum  encroaches  upon  its 
space,  and  that  at  each  side  of  the  promontory  there  is  a 
curved  space  which  can  accommodate  a  globular  body  of 
considerable  size.  The  significance  of  this  will  become 
apparent  in  studying  the  mechanism  of  labor. 

The  Pelvic  Cavity. — Beneath  the  brim  of  the  pelvis  is  the 
space  known  as  the  pelvic  cavity,  whose  posterior  wall  is 
formed  by  the  sacrum  and  coccyx;  the  lateral  walls  by  the 
ilia,  ischia,  pubes,  the  greater  portion  of  the  lateral  walls  of 
the  pelvic  cavity  being  made  by  ligamentous  fascia  and  mus- 
cular tissue.  Through  the  pelvic  cavity  runs,  upon  the  left 
side,  the  rectum,  which  encroaches  upon  its  space.  It  is 
through  this  cavity  that  the  fetus  must  pass  in  parturition. 
The  pelvic  cavity  terminates  at  the  strong  muscular  and 
ligamentous  diaphragm,  called  the  pelvic  floor.  It  is  impor- 
tant to  remember  the  irregular  contour  of  the  pelvic  cavity, 
and  the  fact  that  it  is  of  sufficient  size  in  the  normal  woman 
to  permit  the  passage  of  the  fetus  during  labor. 

The  Pelvic  Outlet. — In  the  unimpregnated  patient  the 
pelvic  outlet  practically  does  not  exist.  The  pelvic 
diaphragm  or  floor  is  pierced  by  the  urethra,  the  vagina  and 
the  anus,  but  these  apertures  are  normally  closed  by  sphincter 
muscles.  The  vagina  is  so  situated  that  it  is  upon  the  an- 
terior portion  of  the  pelvic  outlet,  and  hence  to  emerge 


ANATOMY    OF   NORMAL   BONY   PELVIS  23 

through  this  orifice  the  fetus  must  pass  toward  the  front  of 
the  mother's  body,  or  from  behind  forward.  The  bony 
landmarks  of  the  pelvic  outlet  are  the  tuberosities  of  the 
ischia,  which  give  an  idea  of  the  space  between  the  ischia. 
The  depth  of  the  pelvic  outlet  is  inferred  by  obtaining  the 
distance  from  the  lower  border  of  the  pubes  to  the  end  of  the 
coccyx. 

The  Lateral  Walls  of  the  Pelvis. — The  inner  surface  of 
the  ilia  and  ischia  can  be  palpated  by  vaginal  examination. 
These  constitute  an  inclined  plane,  so  directed  that  a  globular 
body  pressed  against  these  surfaces  might  turn  downward 
and  forward.  Our  recent  knowledge,  however,  leads  us  to 
believe  that  these  surfaces  are  of  little  importance  and  that 
the  turning  of  the  child  in  birth  is  produced  by  other  causes. 

The  Pelvic  Planes  and  Axis. — Obviously  the  pelvis  may 
be  minutely  studied  by  passing  an  infinite  number  of  planes 
through  its  cavity.  For  practical  purposes  such  study  is 
too  minute  to  be  useful.  The  function  of  such  planes  is  to 
enable  us  to  ascertain  the  axis  of  the  pelvis,  an  imaginary 
line  at  right  angles  to  each  of  these  planes  thus  constituting 
a  curve.  By  such  study  of  the  dried  pelvis,  and  by  practical 
observation,  we  find  that  the  axis  of  the  pelvis  is  a  line 
directed  into  the  brim  downward  and  backward,  until  it 
strikes  the  anterior  surface  of  the  sacrum  near  the  coccyx. 
As  the  posterior  wall  of  the  pelvis  is  strong  and  unyielding, 
to  emerge  from  the  pelvis  a  moving  body  must  turn  in  the 
direction  of  the  least  resistance,  which  would  be  upward  and 
forward  beneath  the  pubic  joint. 

The  Diameters  of  the  Pelvis. — The  diameters  of  the  pelvis 
are  obtained  by  measuring  between  the  various  bony  land- 
marks, and  such  diameters  are  external  and  internal. 

The  internal  diameters  of  the  pelvic  brim  are  as  follows: 
The  antero-posterior  diameter,  from  the  middle  of  the  prom- 
ontory of  the  sacrum  behind  to  the  middle  of  the  posterior 
surface  of  the  pubic  joint  in  front,  measures  11  cms.  or  4^ 
inches.  This  is  also  termed  the  true  conjugate,  and  is  an 
important  measurement  in  estimating  the  pelvic  size. 

The  transverse  internal  diameter  of  the  pelvic  brim  is  a 
line  drawn  transversely  between  the  two  iliac  bones  at  their 
junction  with  the  ischia  and  in  the  linea  terminalis.  In  the 


24 


MANUAL   OF   OBSTETRICS 


dried  pelvis  this  is  the  largest  diameter  of  the  brim,  measur- 
ing 13.5  cm.,  or  5  plus  inches. 

The  oblique  diameters  extend  from  the  sacro-iliac  joints 
behind  to  the  middle  of  the  pubic  arch  in  front,  and  are 
named  respectively  from  the  sacro-iliac  joints,  right  and  left. 
They  measure  in  the  dried  pelvis  12.75  cm.,  or  4%  inches. 


Fig.  2. — The  diameters  of  the  pelvic  excavation  (Farabeuf  and  Varnier) 

One  can  readily  see  that  in  the  dried  pelvis  at  the  brim  the 
measurement  of  width  is  greatest,  while  the  distance  from 
before  backward  is  least. 

While  mathematically  an  infinite  number  of  diameters 
may  be  devised  for  the  study  of  the  pelvic  cavity,  such  is 
impracticable,  and  an  average  diameter  is  usually  considered. 


ANATOMY   OF   NORMAL   BONY   PELVIS  25 


Such  would  be  from  12  to  13  cm.,  or  4J^  to  5  inches.  The 
practical  importance  of  this  measurement  lies  in  the  fact  that 
it  is  sufficiently  large  to  permit  the  head  of  a  normal  fetus 
completely  flexed  or  extended,  to  rotate  within  the  pelvic 
cavity. 

The  outlet  of  the  pelvis,  or  inferior  strait,  measures  from 
side  to  side  between  the  tuberosities  of  the  ischium,  11  cm., 
or  4}^  inches;  from  the  pubes  to  the  coccyx,  the  average 
measurement  is  9.5  cm.,  or  3%  inches,  which  is  increased 
during  birth  by  the  backward  movement  of  the  coccyx  on 
the  sacrum  to  5  inches. 

The  External  Diameters  of  the  Pelvic  Brim.  —  It  is  prac- 
tically impossible  to  measure  the  pelvic  brim  accurately  in 
the  living  patient,  and  we  have  recourse  to  bony  landmarks, 
which  by  external  measurement  give  us  a  fairly  accurate 
idea  of  the  pelvic  size. 

We  measure  the  width  of  the  pelvic  brim  by  taking  the 
distance  between  the  anterior  superior  spines  of  the  ischia  — 
26  cm.,  or  10  inches.  Another  measure  of  width  is  obtained 
by  measuring  between  the  outermost  points  of  the  iliac 
crests  —  28^  cm.,  or  11  inches;  and  a  further  measure  of 
width  is  afforded  by  the  distance  between  the  trochanters  of 
the  femora  —  32J/2  cm.,  or  13  plus  inches. 

To  obtain  the  diagonal  measurements  externally  of  the 
pelvic  brim,  we  measure  between  the  posterior  superior  spine 
of  the  ilium  on  one  side  to  the  anterior  superior  spine  of  the 
ilium  on  the  opposite  side  —  a  distance  of  22  to  23  cm.,  or  8 
plus  inches.  Of  this,  the  right  measurement  is  often  slightly 
larger  than  the  left. 

To  obtain  the  antero-posterior  diameter  of  the  pelvis  ex- 
ternally, we  measure  from  beneath  the  last  lumbar  vertebra 
to  the  middle  of  the  external  surface  of  the  pubic  joint  —  20^2 
cm.,  or  8  inches.  Through  measurements  of  large  numbers 
of  sacra,  we  know  that  the  average  thickness  of  the  sacrum 
and  pubis  is  3^  inches,  and  subtracting  ^lls,  we  obtain  4*/£ 
inches  for  the  true  conjuga*  or  internal  antero-po.sterior 
diameter. 

When  we  attempt  to  measure  the  internal  antero-posterior 
diameter  by  vaginal  examination,  we  can  sometimes  touch 
the  promontory  of  the  sacrum  with  the  tip  of  the  longest 


26  MANUAL    OF    OBSTETRICS 

finger,  and  noting  where  the  hand  inserted  bears  against  the 
lower  edge  of  the  pubic  joint,  we  obtain  the  measurement  from 
the  promontory  of  the  sacrum  to  the  lower  edge  of  the  pubis. 
This,  however,  is  not  what  is  desired,  for  we  cannot  measure 
with  the  hand  between  the  upper  edges  of  the  pubis  pos- 
teriorly and  internally,  and  the  promontory  of  the  sacrum. 
We  must  deduct  from  this  the  height  of  the  pubis.  The 
measurement  just  described  is,  on  the  average,  13^  cm., 
and  the  average  height  of  the  pubis  may  be  taken  as  2  cm.; 
and  deducting  2  from  13^  gives  us  lljXj  for  the  interior 
antero-posterior  diameter,  or  true  conjugate,  or  4^  to  4}/2 
inches. 

A  further  external  measurement  useful  for  comparison  is 
the  pelvic  circumference  obtained  by  passing  a  tape-line 
around  the  pelvis  just  beneath  its  crest,  and  meeting  at  the 
pubic  joint.  This  in  normal  subjects  varies  from  85  to 
90cm. 

Pelvic  Inclination. — It  is  obvious  that  the  pelvis  is  not 
perpendicular,  but  that  the  sacrum  is  inclined  forward  and 
the  coccyx  backward.  This  tipping  or  inclination  of  the 
pelvis  is  of  practical  importance  in  directing  downward  the 
child  in  its  passage  through.  It  varies  greatly  with  the 
posture  of  the  patient  and  with  various  conditions,  and  it  is 
not  of  great  practical  importance. 

The  Pelvic  Joints. — We  must  again  draw  attention  to  the 
sacro-iliac  and  pubic  joints.  They  are  of  great  importance, 
for  during  labor  they  perform  the  true  function  of  a  joint 
in  permitting  motion  of  the  two  elements  which  make  the 
joint.  While  the  fetus  accommodates  itself  to  the  pelvis 
during  parturition,  the  pelvis  also  accommodates  itself  to 
the  fetus,  and  this  is  possible  because  the  pelvic  joints  are 
true  joints,  permitting  motion.  In  normal  cases  the  pelvic 
joints  are  unusually  mobile  during  pregnancy,  but  regain 
their  slight  mobility  only  when  the  mother  recovers  from 
labor.  .  In  cases  01  complicated  birth  or  disease  of  the  pelvic 
joints  they  may  become  ankylosed  or  may  remain  unusually 
mobile,  both  conditions  affecting  seriously  the  health  of  the 
mother. 

The  Difference  Between  the  Male  and  the  Female  Pelvis. 
— Early  in  the  intrauterine  life,  with  the  determination  of 


ANATOMY   OF   NORMAL   BONY   PELVIS  27 

sex,  the  fetus  develops  the  essential  characteristics  of  its 
pelvis.  The  male  pelvis  has  heavier  bones  than  the  female, 
its  walls  are  longer,  it  is  narrower,  the  surfaces  for  muscular 
attachment  are  larger  and  rougher,  and  the  pubis  is  narrow 
instead  of  flaring  widely  outward.  Thus,  the  outlet  of  the 
male  pelvis  is  much  smaller  than  that  of  the  female. 

The  Child's  Pelvis. — While  the  sex  of  the  child  may  early 
be  developed,  the  pelvis  has  characteristic  shape.  The 
bones  contain  more  cartilage  than  those  of  the  adult;  the 
spine  has  little  curve;  the  pelvic  brim  is  higher;  and  the  pro- 
jection of  the  promontory  of  the  sacrum  much  less.  The 
child's  pelvis  has  far  less  space,  relatively  speaking,  so  that 
the  bladder  which  is  often  in  the  pelvis  of  the  adult,  is  an 
abdominal  organ  in  the  young  child. 

The  Forces  Developing  the  Pelvis. — As  the  pelvis  is  com- 
posed of  elastic  living  tissue,  it  grows  with  the  rest  of  the 
body.  Two  forces  are  of  great  importance  in  its  develop- 
ment: One  is  the  weight  of  the  head  and  trunk  pressing 
downward  upon  the  promontory  of  the  sacrum.  This  force 
would  separate  the  sacrum  from  the  ilia  were  it  not  for  the 
sacro-iliac  ligaments.  The  force  from  above  downward  is  re- 
sisted by  the  strength  of  the  curved  lateral  walls  of  the  pelvis 
acting  in  principle  like  the  mechanical  arch. 

Opposing  these  forces  from  above  downward,  and  exerted 
at  an  obtuse  angle  to  its  direction,  is  the  force  transmitted 
through  the  lower  extremities  and  through  the  necks  of  the 
femora.  To  resist  this  the  lateral  halves  of  the  pelvis  assume 
their  curved  shape  as  the  child  grows  sufficiently  old  to  walk 
and  to  take  exercise.  The  shape  of  the  pelvis  then  is  largely 
determined  by  these  two  forces,  and  in  cases  where  the  child 
does  not  walk,  but  is  able  to  sit,  the  pressure  from  above 
downward  causes  the  promontory  to  project  unduly,  while 
the  lack  of  lateral  force  results  in  failure  in  the  development 
of  the  two  pelvic  halv 

The  pelvis  also  has  motion  upon  the  sacrum  at  the  sacro- 
iliac  joints,  and  the  two  halves  of  the  pelvis  are  bound  to- 
gether by  the  pubic  and  sacro-iliac  ligaments  as  the  two  piers 
of  a  cantilever  bridge  are  fastened.  The  two  halves  of  the 
pelvis  rotate  asunder,  and  if  the  two  piers  of  the  bridge  be 
severed  by  cutting  the  pubic  ligaments  the  two  halves  move 


28  MANUAL   OF   OBSTETRICS 

upward  and  outward,  because  the  opposite  ends  are  heavily 
weighted. 

Accident,  lack  of  proper  food  and  disease,  interfere  with 
the  normal  development  of  the  pelvis,  producing  deformity. 
The  shape  of  the  pelvis  varies  in  different  races,  in  accordance 
with  the  contour  of  other  parts  of  the  skeleton.  The  pelvis 
varies  considerably  in  size  in  different  individuals,  without 
deformity. 

A  knowledge  of  the  form,  size  and  functions  of  the  pelvis 
is  of  paramount  importance  in  obstetric  study. 


CHAPTER   II 
THE  ANATOMY  OF  THE  ABNORMAL  BONY  PELVIS 

The  Infantile  Pelvis. — This  pelvis,  from  causes  usually 
unknown,  does  not  assume  the  characteristic  female  type, 
but  remains  small  and  ill-developed.  It  is  symmetrical, 
resembling  essentially  the  male  pelvis.  Its  diminutive  size 
and  male  type  make  the  diagnosis  of  infantile  pelvis.  Ob- 
viously it  would  create  a  barrier  to  labor  should  impregnation 


I  ig.  3. — Infantile  pelvis. 

occur  in  such  an  individual,  mile      the  child   wrc   corre- 
spondingly small  and  imperfect. 

The  Generally  Contracted  or  Justo-Minor  Pelvis. — T.iis 
pelvis  has  the  essential  shape  of  the  female  type,  but  is  below 
the  average  in  diameter.  It  is  not  deformed,  and  is  usuallv 
seen  in  tall,  unusually  slender,  and  ill-developed  women. 

29 


30 


MANUAL    OF   OBSTETRICS 


Such  a  person  has  hips  so  narrow  that  the  size  of  the  pelvis 
can  be  inferred  by  observing  the  breadth  of  the  hips.     Other 


Fig.  4. — Justo-minor  pelvis. 

portions  of  the  skeleton  are  correspondingly  narrow,  as  the 
thorax,  the  neck,  and  often  the  face.     Here  again  this  pelvis 


Fig.  5. — Flat  rhachitic  pelvis. 

nmy  occasion  serious  difficult}"  in  labor,  unless  the  child  be 
correspondingly  small  and  ill-developed. 


ANATOMY  OF  ABNORMAL  BONY  PELVIS 


31 


v 


The  Symmetrically  Large  or  Justo-Major  Pelvis. — The 
opposite  of  the  preceding,  this  pelvis  has  the  characteristic 
female  type  and  is  larger  than  the  average  in  all  diameters. 
It  is  symmetrical  and  is  usually  found  in  short,  broad- 
shouldered  women  with  wide  hips.  It  is  often  accompanied 
by  very  strong  muscles  and  vigorous 
general  health.  Such  women  frequently 
give  birth  to  large  and  well  developed 
children  without  abnormal  mechanism 
in  labor.  Should,  however,  the  child  be 
smaller  in  proportion  than  the  pelvis, 
abnormal  presentation  or  position  may 
result. 

The  Simple,  Flat  Pelvis.— In  this  pel- 
vis, through  some  fault  of  development, 
the  promontory  of  the  sacrum  projects 
further  forward  than  normal,  thus  lessen- 
ing the  internal  antero-posterior  diameter 
of  the  pelvis.  It  is  often  difficult  to  ac- 
curately recognize  the  cause  of  flattened 
pelvis,  but  in  some  cases  the  child  has 
been  ill-nourished  and  has  been  urged  to 
stand  and  to  walk  too  early.  This  pelvis 
is  deformed  only  in  the  antero-posterior 
diameter,  and  thus  may  readily  escape 
detection  unless  the  pelvis  is  measured. 

Flat  Rhachitic  Pelvis. — This  pelvis  is 
not  only  small  in  all  diameters,  but  flat- 
tened as  well.  It  is  found  in  persons  ill- 
developed  and  where,  in  addition,  there 
has  be°i  some  circumstance  or  condition 
which  led  to  the  downward  and  forward 
pressure  upon  the  promontory  of  the 
sacrum. 

Imperfect  Development  in  Various  Por- 
tions of  the  Pelvis. — Sometimes  one  portion  of  the  pelvis 
only  is  ill-developed,  the  remainder  being  normal, 
abnormality  is  most  frequently  seen  in  the  sacrum, 
one  wing  is  deficient,  the  pelvis  is  styled  Naegele;  when  both 
are  imperfect,  the  Robert. 


Fig.  6. — Woman 
with  flat  pelvis  (af- 
ter Stratz). 


Such 
When 


32 


MANUAL    OF   OBSTETRICS 


The  Rhachitic  Pelvis. — Rhachitis  is  very  commonly  ob- 
served among  negroes,  less  frequently  among  the  whites. 
If  present  in  any  considerable  degree  it  alters  the  size  and 
shape  of  the  pelvis. 

Rhachitis  is  essentially  an  overgrowth  of  ill-developed 
bone,  at  first  unduly  soft  and  yielding,  which  results  in  de- 
formity of  the  pelvis  through  pressure,  and  then  hardening 
into  unusually  thick  bone,  causing  deformity  and  lessened 
space  through  abnormal  thickness.  The  most  important 
feature  of  the  rhachitic  pelvis  is  the  loss  of  contour  at  the 


Fig.  7. — Irregularly  deformed  rhachitic  pelvis  with  scoliosis. 

brim.  This  may  be  recognized  by  taking  the  external 
measurements  of  the  pelvis,  when  it  will  be  found  that  the 
distance  between  the  spines  of  the  ilia  is  equal  to  or  greater 
than  the  distance  between  +.he  outermost  points  of  the 
crests.  At  the  pelvic  brim  the  pelvis  may  or  may  not  be 
flattened.  The  pelvic  brim  is  rarely  symmetrical,  but  is 
ofteii  deformed  by  the  oblique  projection  of  the  promontory 
and  sacrum.  Other  portions  of  the  pelvis  may  be  deformed, 
•hus  altering  considerably  the  shape  of  the  pelvic  cavity. 
The  degree  of  contraction  varies  from  slight  contraction  to 
euch  which  makes  it  impossible  for  the  pelvic  organs  to  enter 


ANATOMY  OF  ABNORMAL  BONY  PELVIS 


33 


the  pelvis,  and  which  renders  the  birth  of  the  fetus  at  any 
stage  of  fetal  existence  impossible.  Together  with  pelvic 
deformity,  the  patient  shows  the  general  signs  of  rhachitis. 


Fig.  8. — Obliquely  contracted  deformed  pelvis. 


Fig.  9. — Funnel-shaped  pelvis. 

I 

The  cranium  is  unusually  broad,  the  forehead  projecting,  and 
the  cranial  bones  unusually  thick  and  hard.     The  sternum 
may  be  deformed  and  the  patient  may  be  pigeon-breasted. 
3 


34 


MANUAL    OF   OBSTETRICS 


The  articulations  of  the  ribs  with  the  sternum  are  enlarged 
and  can  plainly  be  felt.  The  epiphyses  of  the  long  bones 
are  enlarged,  the  lower  extremities  bent  and  the  patient's 
general  appearance  is  that  of  disease  and  abnormality  in  the 
skeleton.  Often  the  vertebras  at  the  brim  of  the  pelvis  are 
altered,  the  promontory  of  the  sacrum  may  be  double,  or  the 
sacrum  greatly  thickened  and  projecting.  Contraction  in 
various  degrees  may  accompany  rhachitis  throughout  the 
pelvis,  so  that  no  typical  shape  can  be  given  for  the  rhachitlc 
pelvis;  but  each  case  must  be  studied  upon  its  individual 
condition.  The  tendency  of  the  rhachitic  pelvis,  if  the 


Fig.  10. — Osteomalacic  pelvis. 

patient  lives  through  childhood  to  adult  life,  is  to  become 
heavier  and  firmer  than  normal.  The  pelvic  joints  are  often 
less  mobile  than  in  the  average  patient,  and  the  pelvic  bones 
harder  than  usually  found. 

The  Osteomalacia  Pelvis. — This  disease  is  a  process  of 
softening  affecting  the  pelvis,  vertebrae  and  ribs.  The  bones 
become  soft,  lighter  in  weight,  and  readily  bent.  The  con- 
dition is  seen  in  adults  and  is  attended  with  pain  throughout 
the  bones,  somewhat  resembling  rheumatic  pain.  As  the 
softening  increases  the  patient  is  unable  to  stand  or  sit  and 
is  finally  confined  to  her  bed.  That  the  disease  is  connected 


ANATOMY  OF  ABNORMAL  BONY  PELVIS 


35 


in  some  way  with  the  presence  and  activity  of  the  ovaries 
is  indicated  by  the  fact  that  the  removal  of  the  ovaries  often 
stops  the  progress  of  the  disease. 

The  deformity  produced  by  osteomalacia  has  no  regular 
type.  The  two  halves  of  the  pelvis  bend  inward  toward  the 
center;  the  promontory  of  the  sacrum  projects  downward, 
and  usually  to  one  side.  While  the  con- 
dition is  comparatively  rare  in  this 
country  the  diagnosis  is  not  difficult, 
from  the  marked  deformity  and  clinical 
history. 

Spinal  Deformity  Affecting  the  Pel- 
vis.— The  projection  forward  or  back- 
ward of  the  vertebrae  at  the  pelvic  brim 
may  complicate  labor  and  deform  the 
patient.  To  sustain  the  weight  of  the 
body  the  projection  backward  of  the 
vertebrae  in  one  portion  of  the  spinal 
column  is  compensated  by  a  projection 
forward  in  another  portion  of  the  spine; 
so  in  the  hunchback  the  kyphosis  or 
backward  projection  of  the  lumbar,  and 
possibly  upper  sacral  vertebrae,  is  bal- 
anced by  the  projection  forward  in  the 
dorsal  region,  which  is  known  as  lordosis. 
While  such  abnormality  in  the  spinal  col- 
umn may  not  actually  deform  the  pelvis, 
it  alters  the  shape  and  capacity  of  the 
abdomen  and  chest  and  brings  the  uterus 
into  abnormal  relation  with  the  pelvis  at 
birth.  It  may  accompany  bony  deform- 
ity; so  a  lateral  curvature  of  the  spine, 
scoliosis,  may  interfere  with  normal  par- 
turition, because  the  uterus  is  not  brought  naturally  in  rela- 
tion with  the  axis  of  the  bony  pelvis. 

The  spinal  column  may  also  be  deforced  in  its  junction 
with  the  sacrum.  The  last  lumbar  vertebrae  may  be  par- 
tially dislocated  and  rotated  upon  the  sacrum.  Conditions 
known  as  spondylolisthesis  and  spondylizema  are  illustra- 
tions of  such  deformity. 


Fig.  11. — Woman 
with  kyphotic 
pelvis. 


36 


MANUAL   OF    OBSTETRICS 


The  Effect  of  Lameness  or  Injury  Upon  the  Pelvis. — As 
the  pelvis  develops  in  response  to  the  stimulus  of  exercise, 
so  in  a  growing  girl  who  has  disease  preventing  exercise,  the 
pelvis  may  become  deformed.  In  a  case  observed  by  the 
writer,  a  young  woman,  when  thirteen  years  of  age  had  tuber- 
cular disease  of  the  right  knee-joint.  For  this  she  was  kept  in 
bed  for  the  greater  part  of  a  year.  She  improved  somewhat 
and  upon  motion  became  worse,  was  again  in  bed,  and  finally 
had  resection  of  the  joint.  The  right  lower  extremity  was 
practically  paralyzed  for  several  years.  As  a  result  of  this  the 


Fig.  12. — Spondylolisthesis. 


right  oblique  diameter  of  the  pelvis  was  permanently  short- 
ened, and  when  she  became  an  adult,  and  pregnancy  and 
labor  occurred,  difficulty  resulted. 

One  may  readily  see  how  paralysis  of  the  lower  extremi- 
ties would  result  ir  considerable  diminution  in  the  size  of  the 
pelvis. 

The  pelvis  may  be  deformed  by  direct  mechanical  vio- 
lence; thus,  a  young  girl  fell  from  a  tree,  striking  upon  her 
hip,  breaking  the  neck  of  the  femur,  and  driving  it  through 


ANATOMY   OF   ABNORMAL   BONY    PELVIS  37 

11  ic  acetabular  cavity.  The  callus  which  formed  and  the 
impacted  fracture  persisted,  and  when  grown  and  in  the 
pregnant  condition  vaginal  examination  showed  that  side 
of  the  pelvis  much  deformed  and  much  smaller  than  the 
other. 

Pelvic  Abnormality  Caused  By  Disease. — The  pelvic  bones 
may  become  necrotic,  the  pelvic  joints  tubercular,  and  the 
shape  and  size  of  the  pelvis  altered  in  consequence.  The 
growth  of  tumors  springing  from  the  periosteum  or  bony 
tissue,  as  osteo-sarcoma  or  enchondroma,  may  greatly  lessen 
the  capacity  of  the  pelvis. 

Pelvic  Deformity  From  Dislocation. — As  a  result  of  dis- 
ease, or  failure  of  development,  the  mobile  parts  of  the  pelvis 
may  become  permanently  displaced  and  deformity  result. 
When  by  accident  or  injury  the  coccyx  has  been  broken,  or 
the  sacro-coccygeal  joint  partially  torn  asunder,  bony  union 
may  occur  at  a  considerable  angle,  and  the  coccyx  lose  its 
normal  motility. 

In  a  patient  seen  by  the  writer,  the  coccyx  had  been  injured 
while  riding,  and  some  years  later  when  labor  occurred  it 
was  immobile  and  offered  a  considerable  obstruction  to  the 
birth  of  the  child. 

Congenital  dislocation  of  one  or  both  femora  may  interfere 
with  the  development  and  the  normal  size  of  the  pelvis. 

The  Frequency  of  Abnormal  Pelves. — In  1224  patients 
examined  by  the  writer,  by  external  and  internal  measure- 
ment, 25  per  cent,  had  pelves  smaller  than  the  average. 
These  patients  included  all  races  in  this  country,  except 
Chinese  and  Indians.  Various  observers  differ  in  the  state- 
ment as  to  which  is  the  most  common  variety  of  abnormal 
pelvis.  Among  whites,  the  justo-minor  or  generally  con- 
tracted pelvis  is  not  uncommon  in  those  who  have  been  badly 
nourished  children,  from  luxury,  or  from  want.  Among 
negroes,  the  rhachitic  pelvis  is  common.  It  may  be  said 
that  among  white  persons  the  most  usual  deformities  of  the 
pelvis  are  those  resulting  from  lack  of  development  in  native 
Americans.  In  Europeans  coming  from  the  peasantry, 
where  hygienic  conditions  are  bad,  and  want  prevails,  rha- 
chitis  and  osteomalacia  are  observed.  Certainly  one-third 
of  the  pelves  coming  under  observation  among  obstetricians 


38  MANUAL   OF   OBSTETRICS 

differ  somewhat  from  the  average  in  size  or  contour.  This 
fact  should  emphasize  the  necessity  for  measuring  the  pelvis 
and  for  studying  the  comparative  size  of  the  fetus  in  all 
primiparous  patients. 

The  diagnosis  of  pelvic  deformity  will  be  considered  under 
the  complete  examination  of  the  pregnant  woman. 


CHAPTER   III 
PHYSIOLOGY   OF   IMPREGNATION 

The  Physiology  of  Normal  Impregnation. — Impregnation 
occurs,  as  physiology  teaches  us,  by  the  union  of  the  ovum  and 
spermatozoa.  In  normal  pregnancy  the  impregnated  ovum 
passing  from  the  Graafian  follicle  in  the  ovary,  enters  the 
Fallopian  tube  through  its  fimbriated  extremity  and  passes 
along  the  tube  to  the  interior  of  the  uterus.  This  motion  is 
effected  largely  by  the  ciliated  epithelia  lining  the  Fallopian 
tube.  The  passage  of  the  ovum  from  the  ovary  to  the  in- 
terior of  the  uterus  occupies  a  varying  period  whose  exact 
duration  is  unknown,  but  which  is  frequently  several  days 
in  duration.  As  soon  as  impregnation  occurs  a  change 
develops  in  the  lining  membrane  of  the  uterus.  This  be- 
comes sensitized  to  the  ovum,  its  circulation  of  blood  in- 
creases, and  it  is  in  a  condition  favorable  for  the  lodgment 
and  attachment  of  the  ovum.  Entering  the  uterus  through 
the  Fallopian  tube  the  ovum  normally  lodges  and  attaches  it- 
self on  the  uterine  surface  at  about  the  middle  of  the  upper 
expulsive  segment  of  the  uterus.  The  exact  point  of  its 
attachment  is  determined  by  the  normal  development  of  the 
uterus  and  by  the  healthy  condition  of  its  lining  membrane. 
The  successful  development  of  the  ovum  depends  upon  its 
normal  attachment,  for  if  it  fails  to  enter  the  uterine  cavity 
it  cannot  develop,  and  if  it  becomes  attached  to  the  dilatable 
portion  of  the  uterus  it  cannot  go  to  full  term  without  danger 
to  the  mother  and  fetus  through  hemorrhage.  As  the  uterus 
is  originally  developed  in  two  halves,  joined  in  the  centre,  the 
ovum  may  normally  develop  almost  entirely  upon  one  side 
of  the  uterus,  thus  producing,  as  pregnancy  advances,  an 
abnormal  projection  of  this  portion  of  the  uterus,  which  may 
be  mistaken  for  an  abnormality  in  the  womb,  and  occasion- 
ally for  a  fibroid  tumor.  In  such  cases  when  labor  is  over 
the  uterus  resumes  its  normal  contour. 

39 


40  MANUAL   OF   OBSTETRICS 


THE  PHYSIOLOGY   OF  ABNORMAL   IMPREGNATION 

Instead  of  proceeding  into  the  uterine  cavity  for  its  final 
lodgment  the  impregnated  ovum  may  remain  in  the 
Graafian  follicle  and  the  ovary,  in  the  Fallopian  tube,  in  the 
wall  of  the  uterus,  or  attach  itself  to  the  distensile  portion 
of  the  womb  in  the  lower  uterine  segment,  as  low  as  the 
internal  os.  This  is  called  ectopic  pregnancy.  When  the 
impregnated  ovum  lodges  in  the  Graafian  follicle  or  adheres 
to  any  portion  of  the  ovary,  it  is  called  ovarian  pregnancy. 
Obviously  the  ovum  cannot  grow  large  in  this  position  and 
must  attach  itself  partly  to  surrounding  tissue,  peritoneum, 
intestine,  omentum  or  mesentery,  if  its  life  is  to  continue. 
So  an  ovarian  pregnancy  is  recognized  microscopically  by 
finding  in  some  portion  of  the  sac  of  the  embryo  or  fetus 
ovarian  tissue,  showing  that  the  embryo  originally  was  at- 
tached to  the  ovary. 

If  the  impregnated  ovum  lodges  in  the  Fallopian  tube  it 
may  there  develop  until  it  has  grown  so  large  that  the  tube 
can  no  longer  contain  it.  Its  presence  may  excite  the  con- 
traction of  the  elastic  and  unstriped  muscle  tissue  of  the 
tube,  and  the  ovum  may  be  forced  out  through  the  fimbriated 
extremity  in  tubal  abortion.  It  may  still  live  by  attaching 
itself  to  omentum,  mesentery,  or  intestine,  when  it  becomes 
an  abdominal  pregnancy. 

If  it  does  not  escape  through  the  fimbriated  extremity  of 
the  tube,  it  may  burst  the  Fallopian  tube,  and  if  considerable 
hemorrhage  occurs  the  ovum  will  die,  and  sometimes  the 
mother  also.  Should  this  not  occur,  the  ovum  may  lodge  be- 
tween the  layers  of  the  broad  ligament  and  develop  to  a 
considerable  extent  in  that  position  and  escape  into  the 
abdominal  cavity  to  nearly  full  term  among  the  intestines. 
It  then  becomes  an  abdominal  pregnancy. 

If  the  impregnated  ovum  lodges  in  the  Fallopian  tube  as 
it  passes  through  the  wall  of  the  uterus  at  the  uterine  cornu, 
it  may  develop  for  some  weeks  as  an  interstitial  pregnancy. 
It  will  finally  escape  into  the  cavity  of  the  uterus,  or  rupture 
the  uterine  wall  and  be  expelled  into  the  pelvic  or  abdominal 
cavity.  It  will  then  cause  hemorrhage  and  symptoms  like 
those  of  ruptured  tubal  gestation. 


PHYSIOLOGY    OF   ABNORMAL    IMPREGNATION  41 

If  the  impregnated  ovum  lodges  below  its  normal  point 
of  attachment  it  will  adhere  to  the  lower  uterine  segment. 
This  must  dilate  while  labor  occurs  and  becomes  gradually 
stretched  as  the  fetus  grows.  The  placenta  by  which  the 
fetus  is  attached  to  the  womb  will  then  become  partially  or 
wholly  separated,  and  in  many  cases  the  death  of  the  mother 
and  child  results  from  hemorrhage.  The  ovum  may  attach 
itself  so  low  upon  the  lower  segment  of  the  womb  as  to  extend 
across,  completely  covering  the  internal  os.  The  low  at- 
tachment of  the  impregnated  ovum  is  a  form  of  ectopic 
gestation,  commonly  known  as  placenta  prgevia. 


CHAPTER  IV 

THE  ANATOMY  OF  THE  BIRTH  CANAL  IN 
PREGNANCY 

As  a  result  of  pregnancy,  the  generative  organs  and  pelvis 
undergo  changes  adopted  for  the  growth  of  the  ovum  and 
the  final  expulsion  of  the  fetus. 

The  Ovary  in  Pregnancy. — There  is  no  conclusive  evidence 
that  the  ovary  as  a  gland  is  greatly  altered  during  pregnancy. 
The  Graafian  follicle,  whence  comes  the  impregnated  ovum, 
undergoes  the  usual  process  of  contraction,  with  the  forma- 
tion of  corpus  luteum.  This  is  colored  differently  and  more 
brilliantly  in  pregnancy  than  in  the  non-pregnant,  the  color 
varying  in  different  warm-blooded  animals.  In  the  human 
species  the  color  is  dark  yellow  or  orange,  and  pregnancy  may 
be  recognized  by  the  characteristic  appearance  of  the  corpus 
luteum.  The  position  of  the  ovary  varies  from  the  normal 
during  pregnancy,  as  the  ovaries  and  tubes  are  drawn  up- 
ward by  the  growing  uterus  through  stretching  of  the  broad 
ligaments  until  they  are  frequently  found  at  full  term  con- 
siderably above  the  pelvic  brim.  As  the  uterus  is  usually 
rotated  from  left  to  right  as  pregnancy  advances,  the  right 
tube  and  ovary  will  be  further  posteriorly  at  the  pelvic  brim 
than  normal,  and  the  left  tube  and  ovary  further  anteriorly. 

The  Fallopian  Tubes. — The  Fallopian  tubes  share  in  the 
changes  which  occur  in  the  pregnant  uterus.  They  become 
more  vascular,  the  lining  membrane  forming  a  secretion 
which  is  supposed  to  nourish  the  impregnated  ovum  while  it 
remains  in  the  tube.  The  position  of  the  tubes,  as  has  been 
stated,  varies  somewhat  with  the  period  of  pregnancy  and 
the  growth  of  the  womb. 

The  Uterus. — So  soon  as  pregnancy  occurs  the  lining 
membrane  of  the  womb  or  endometrium  undergoes  new  and 
remarkable  cell  activity.  Large  oyster-shape  cells  form  upon 
the  surface  of  the  endometrium,  which  can  be  recognized 

42 


ANATOMY   OF   BIRTH   CANAL   IN   PREGNANCY  43 

upon  microscopic  examination,  and  which  constitute  the 
decidual  cells.  The  glands  in  the  endometrium,  called  utric- 
ular,  increase  in  size  and  form  albuminoid  secretion,  furnish- 
ing nourishment  to  the  embryo  until  the  placenta  forms. 
The  decidual  cells  gradually  form  a  membrane,  known  as 
the  deciduous  membrane,  which  lines  the  uterus  and  is 
reflected  upon  the  ovum,  completely  enclosing  it. 


Fig.  13. — The  birth-canal  during  labor;    CR  to  vi,  lower  uterine  seg- 
ment; oi  to  oe.  cervix. 

The  blood  vessels  of  the  uterus  increase  in  capillary  forma- 
tion, and  as  pregnancy  proceeds  the  circulation  of  the 
uterus  becomes  very  free  and  greatly  enlarged.  The  mus- 
cular tissue  of  the  uterus  develops  in  longitudinal,  circular 
and  oblique  fibres  by  the  multiplication  of  muscle  nuclei. 
With  this  there  is  accompanying  growth  of  connective  and 
elastic  tissue,  and  the  sinuses  or  blood  vessels  of  the  uterus 
develop  until  at  term  they  are  large  enough  to  admit  an  ordi- 


44  MANUAL   OF    OBSTETRICS 

nary  lead  pencil.  With  the  growth  of  the  uterine  muscle 
is  the  development,  from  its  ganglia,  of  the  nerves  which  sup- 
ply this  muscle.  The  entire  growth  of  the  uterus  as  a  hollow 
muscular  organ  is  from  10  to  12  times  its  original  size,  the 
thickness  of  the  uterine  muscle  depending  upon  the  vigor 
and  general  muscular  development  of  the  mother  and  her 
primlparity  or  multiparity.  The  muscular  tissue  of  the 
uterus  comprises  seven-eighths  of  its  entire  length.  The 
remaining  one-eighth  is  the  elastic  portion,  just  above  the 
cervix,  known  as  the  lower  uterine  segment,  the  upper  being 
called  the  expulsive  upper  segment.  The  lower  segment 
contains  little  muscular  tissue  and  is  composed  of  elastic  and 
dilatable  tissue  comparatively  thin.  This  lower  segment 
may  be  recognized  early  in  pregnancy  by  its  thinness  and 
elasticity,  and  the  lower  edge  of  the  upper  expulsive  segment 
projecting  above  it,  upon  pressure.  As  pregnancy  advances 
the  lower  segment  becomes  gradually  distended  by  the  pre- 
senting part  of  the  fetus  and  has  an  influence  in  determining 
and  maintaining  the  presentation  of  the  child.  As  it  is  the 
thinnest  portion  of  the  uterus  at  term,  it  is  obvious  that  the 
uterus  will  tear  most  readily  at  this  part. 

The  cervix  during  pregnancy  is  not  altered  in  length.  In 
consistence  it  changes  greatly,  becoming  much  softened  as 
pregnancy  advances.  Its  glands  secrete  a  tenacious  mucus, 
which  forms  a  plug,  effectually  closing  the  cervical  canal. 
As  pregnancy  advances  the  internal  or  external  os  dilates 
somewhat,  in  proportion  as  the  patient  is  primipara  or 
multipara. 

The  Broad  Ligaments. — These  important  sheets  of  fascia 
which  support  the  uterus,  tubes,  and  ovaries,  share  in  the 
general  hyperemia  of  the  generative  tract.  They  become 
much  more  elastic  than  normal  and  the  veins  of  the  broad 
ligaments  become  enormously  distended.  At  term  these 
veins  are  often  as  large  as  the  little  finger,  and  obviously 
their  rupture  must  be  followed  by  alarming  hemorrhage. 
They  form  dark-bluish  masses  at  the  sides  of  the  lower 
part,  of  the  uterus,  which  illustrate  the  plethora  of  the  free 
blood  supply  of  the  growing  womb.  Their  distended 
plethoric  condition  renders  them  fit  receptacles  for  infective 
bacteria. 


ANATOMY   OF   BIRTH    CANAL   IN    PREGNANCY  45 

The  Vagina  and  Pelvic  Floor. — During  pregnancy  this 
portion  of  the  generative  tract  shares  in  the  general  hyper- 
emia.  The  mucous  membrane  is  engorged  and  dark  red- 
dish-blue in  color  and  secretes  a  thick  and  acid  mucus. 
Pulsation  of  the  vessels  can  be  plainly  felt,  the  discoloration 
of  the  tissues  extending  to  the  external  genital  organs.  The 
glands  about  the  entrance  to  the  vagina  frequently  secrete 
abundantly,  and  the  veins  about  the  external  organs  become 
distended,  like  the  veins  of  the  broad  ligaments,  and  fre- 
quently are  varicose. 

The  muscular  and  elastic  tissues  of  the  pelvic  floor  develop, 
becoming  more  elastic  and  vascular,  and  often  thicker. 

Changes  in  the  Pelvis  Incident  to  Pregnancy. — As  the 
pelvis  is  composed  of  several  bones  united  by  joints,  these 
joints  share  in  the  hyperemia  of  pregnancy.  Synovial  mem- 
brane and  fluid  develop  in  the  sacro-iliac  joints  and  in  the 
sacro-coccygeal  and  pubic  joints.  Motion  is  greatly  in- 
creased and  may  be  sufficiently  great  to  cause  the  patient 
discomfort,  and  to  be  readily  perceptible  upon  examination. 
Rotation  of  the  two  halves  upon  the  sacrum  becomes  pos- 
sible, and  considerable  vertical  movement  of  the  two  halves 
of  the  pubes.  The  coccyx  becomes  much  more  mobile  upon 
the  sacrum.  In  young  women  the  bones  of  the  pelvis  in- 
crease somewhat  in  size  and  vascularity,  and  in  young  girls 
are  considerably  more  elastic  than  normal.  There  is  in- 
creased growth  of  cartilage  in  the  symphysis  pubis. 

The  Length  and  Axis  of  the  Birth  Canal  in  Pregnancy. — As 
the  uterus  rises  in  the  abdomen  and  accommodates  itself  to 
the  available  space,  it  undergoes  changes  in  its  contour  and 
position.  In  early  pregnancy  the  body  of  the  uterus  is 
spherical,  the  uterine  cavity  being  a  round  chamber.  This 
gives  sufficient  space  for  the  free  movement  of  the  embryo 
and  fetus  until  viability  is  attained.  After  this  the  uterus  is 
distinctly  longitudinal,  often  flattened  from  before  backward 
slightly,  and  unilaterally  developed.  The  uterus  rotates 
from  left  to  right  upon  its  axis,  and  at  full  term  is  usually 
found  in  what  is  called  dext retorsion.  Its  contour  varies 
as  pregnancy  advances  with  the  position  and  vigor  of  the 
fetus.  It  undergoes  intermittent  contractions  during  preg- 
nancy in  response  to  the  stimulation  and  fetal  movements 


46  MANUAL   OF   OBSTETRICS 

and  impact,  and  can  be  distinctly  felt  to  alter  its  contour  as 
the  fetus  moves.  Its  size  at  term  depends  upon  the  size  of 
the  fetus,  and  the  stature  and  development  of  the  mother. 

The  position  of  the  uterus  as  pregnancy  continues  depends 
in  a  considerable  degree  upon  the  firmness  or  elasticity  of  the 
mother's  abdominal  muscles  and  the  condition  of  her  abdom- 
inal viscera.  In  primiparae  with  vigorous  muscles  the  abdom- 
inal wall  is  symmetrically  distended  by  the  growing  uterus, 
so  that  the  abdominal  tumor  is  not  especially  noticeable. 
In  these  patients  the  intestines  and  other  abdominal  viscera 
are  held  in  normal  position  by  normal  ligaments,  and  the 
general  shape  of  the  patient's  abdomen  is  not  greatly  altered. 

In  multipart  who  have  repeatedly  borne  children  the  ab- 
dominal wall  is  greatly  distended  and  elastic  and  the  uterus 
frequently  projects  in  a  very  noticeable  manner.  Where 
the  patient  has  suffered  from  chronic  ptosis  of  the  abdominal 
viscera,  when  not  pregnant,  the  growing  womb  may  serve  as 
a  splint  to  carry  upward  and  retain  the  prolapsed  abdominal 
contents.  In  some  cases  this  does  not  occur,  and  in  spite  of 
pregnancy  the  ptosis  continues,  and  to  the  uterine  tumor  is 
added  the  prolapsed  intestine  or  other  viscus.  In  those  who 
suffer  from  chronic  toxemia,  with  accumulation  of  gas,  this 
distention  increases  considerably  the  abdominal  size. 

The  Posture  and  Attitude  of  the  Pregnant  Woman. — In 
the  early  months  of  normal  gestation,  the  posture  and  atti- 
tude of  the  pregnant  woman  are  practically  unaltered.  As 
pregnancy  advances  and  the  weight  of  the  growing  fetus  be- 
comes appreciable,  the  patient  seeks  to  compensate  for  the  size 
and  weight  of  the  abdominal  tumor  by  throwing  the  shoulders 
backward  and  bending  the  upper  spine  backward.  The  shoul- 
ders are  often  squared  as  pregnancy  advances  to  sustain  the 
increased  weight.  In  healthy  women  the  patient  stands  erect 
throughout  pregnancy,  varying  the  curve  of  the  spine  to  meet 
the  indications  present.  In  walking,  the  backward  leaning 
of  the  upper  part  of  the  body  is  often  especially  noticeable. 

The  posture  and  attitude  of  the  pregnant  woman  depend 
considerably  upon  whether  she  allows  herself  to  grow  nor- 
mally during  pregnancy,  or  whether  she  deforms  herself  by 
constricting  clothing.  In  the  former  instance  her  general 
growth,  and  the  adaptation  of  the  trunk  to  the  increasing 


ANATOMY   OF   BIRTH    CANAL   IN    PREGNANCY 


47 


weight,  lessen  greatly  the  apparent  size  of  the  abdominal 
tumor.  The  pregnant  condition  is  much  less  noticeable 
than  in  women  who  endeavor  to  hide  it  by  constricting  the 
waist  and  abdomen.  In  these  patients  the  constriction  may 
force  the  uterus  down  to  the  pelvic  brim,  but  it  will  also 
interfere  with  intestinal  peristalsis,  causing  distention  of  the 
bowel  by  gas,  and  increasing,  if  anything,  the  size  of  the  ab- 


Fig.  14. — Contour,  normal  pregnancy,  full  term. 

domen.  In  patients  illegitimately  pregnant,  who  endeavor 
to  hide  the  condition  by  extreme  pressure  upon  the  abdomen 
and  uterus,  the  womb  may  be  so  altered  in  shape  as  to  be 
mistaken  for  a  fibroid  tumor  or  other  pelvic  or  abdominal 
tumors. 

The  contour  of  the  abdomen  will  depend  somewhat  upon 
the  size  of  the  child  and  the  question  of  single  or  multiple 
pregnancy.  The  greater  the  weight  within  the  uterus  the 


48  MANUAL   OF   OBSTETRICS 

larger,  naturally,  must  be  the  abdominal  tumor.  In  some 
conditions  of  disease,  notably  polyhydramnios,  the  uterus 
may  become  so  distended  with  fluid  as  to  resemble  a  large 
ovarian  cyst,  giving  the  characteristic  size  and  contour  to 
the  abdomen. 

The  Axis  of  the  Birth  Canal  in  Pregnancy. — The  axis  of  the 
birth  canal  in  pregnancy  is  the  line  which  the  fetus  must 


Fig.  15. — Normal  birth  canal,  primipara. 

follow  to  pass  from  the  mother's  womb  to  the  external  world. 
In  normal  cases  this  is  virtually  the  same  throughout  preg- 
nancy. The  line  in  which  expulsive  force  is  exerted  is 
directed  from  the  fundus  of  the  uterus  downward  and  back- 
ward until  the  presenting  part  of  the  fetus,  passing  through 
the  pelvis,  meets  the  resistance  of  the  posterior  pelvic  wall. 
Pressing  against  the  concave  surface  of  the  sacrum  and 


ANATOMY    OF   BIRTH    CANAL   IN    PREGNANCY  49 

upon  the  elastic  muscular  diaphragm  of  the  pelvic  floor  it 
meets  resistance  from  these  tissues  and  seeks  the  point  of 
least  resistance.  This  is  through  the  vagina  at  the  vulvar 
opening.  From  the  sacrum,  coccyx,  and  pelvic  floor,  the 
line  of  force  is  directed  forward  and  upward  at  an  acute 
angle  with  its  first  direction,  until  the  presenting  part 
emerges  at  the  bowel.  The  axis  of  the  birth  canal  at  term 
must  be  remembered  in  all  obstetric  operations  which  deliver 
the  patient  by  traction  through  the  vagina.  If  this  line  be 
followed  in  making  traction,  impaction  of  the  presenting  part 
will  be  avoided,  and  the  mother  will  be  delivered  with  the 
least  injury  to  her  and  to  the  child. 


CHAPTER  V 

THE  GROWTH  AND   DEVELOPMENT   OF  THE 
EMBRYO 

The  embryo  grows  by  the  multiplication  of  cells  through 
segmentation.  This  process  begins  with  the  passage  of  the 
ovum  through  the  oviduct  or  Fallopian  tube.  The  cells  into 
which  the  impregnated  ovum  divide,  separate  into  different 
layers  or  planes  which  have  been  traced  to  twelve  segments. 
These  continue  to  divide,  until  minute  sub-division  has  de- 
veloped. These  cells  have  no  membrane,  a  large,  clear  ves- 
icular nucleus,  while  the  granules  in  the  yelk  which  surround 


Fig.  16. — Human  ovum  of  about  twelve  days  (Reichert) :  A,  side  view; 
B,  front  view. 

the  genital  spot  in  the  ovum,  are  small,  highly  refractile,  and 
almost  round.  As  the  ovum  passes  into  the  uterus  it  dilates 
until  a  bladder-like  body  closes  the  blastodermic  vesicle. 
The  outer  layer  of  cells  multiply  and  grow  thinner,  forming 
a  clear  layer  known  as  the  zona  pellucida. 

The  Ectoderm,  Endoderm,  and  Mesoderm. — The  internal 
group  of  cells  attaches  itself  on  the  circumference  of  the  ves- 
icle. Between  the  two  layers  forms  a  cavity  called  the  seg- 
mentation cavity,  or  cavity  of  the  blastoderm.  The  blasto- 

50 


GROWTH  AND  DEVELOPMENT  OF  EMBRYO        51 

dermic  vesicle  expands,  containing  fluid  secreted  in  the  wall 
of  the  vesicle,  which  derives  its  fluid  from  the  abundant  se- 
cretion furnished  by  the  uterine  glands.  The  inner  thick 
mass  of  cells  gradually  separates  into  two  layers — upper  and 
lower,  external  and  internal — called  the  ectodermic  and  en- 
dodermic.  In  the  centre  gradually  develops  a  canal  or  line, 
called  the  primitive  trace  or  notochord.  Gradually  three  dis- 
tinct layers  of  cells  can  be  recognized,  called  respectively 
from  without  inward,  the  ectoderm,  endoderm  and  meso- 
derm.  These  are  virtually  the  outer,  inner,  and  middle 
layers  of  embryonal  cells. 

The  Growth  of  Organs. — The  body  is  formed  virtually 
from  two  epithelial  tubes,  one  within  the  other.  The  branches 
of  the  inner  tube  produce  many  of  the  viscera,  the  space  be- 
tween the  tubes  forming  the  abdomen  and  thorax.  The 
different  organs  of  the  body  grow  from  layers  of  cells  by  the 
growing  out  or  projecting  of  masses  of  cells,  or  by  the  folding 
in  into  cavities  or  crypts  of  masses  of  epithelium.  It  is 
important  to  know  from  what  layer  of  cells  the  systems  of 
organs  in  the  body  are  formed. 

From  the  ectoderm  come  the  external  organs  of  the  body. 
Such  are  the  skin  or  epidermis,  and  those  structures  which 
grow  from  it,  or  in  it,  such  as  the  hair,  the  sebaceous  and 
sweat  glands,  the  salivary  and  mammary  glands;  also  the 
epithelium  of  the  cornea  of  the  eye  and  the  lens  of  the  eye. 
As  the  external  portion  of  the  body  brings  us  in  relation  with 
the  external  world,  the  nervous  system,  by  which  we  gain 
knowledge  of  things  about  us,  is  formed  from  the  external 
layer;  also  the  organs  of  special  sense,  which  are  largely  com- 
posed of  nervous  matter, — the  eye,  the  organs  of  smell  and 
hearing  and  taste  in  the  mouth.  The  teeth  also  come  from 
this  layer  with  the  skin.  So  does  the  pituitary  body  or  hy- 
pophysis, and  the  epithelial  tissue  about  the  anus  is  naturally 
developed  from  the  outer  layer.  The  appendages  of  the 
fetus,  the  amnion,  chorion  and  placenta  come  also  from  this 
layer. 

The  mesoderm,  or  middle  layer,  furnishes  cells  which  pro- 
duce the  great  epithelial  membranes,  peritoneum  and  pleurae; 
also  the  organs  of  generation,  which  in  the  embryonal  state 
are  developed  with  the  Wolffian  bodies;  and  the  kidneys  as 


52 


MANUAL    OF    OBSTETRICS 


well.  Striped  muscle  comes  also  from  this  layer.  From  the 
cells  of  the  middle  layer  also  are  developed  the  blood,  its 
vessels,  and  the  lymphatics;  the  spleen,  fat  cells  and  embryo, 
the  unstriped  muscle  and  connective  tissue,  and  the  bony 
skeleton. 

The  inner  layer  forms  the  viscera  which  have  to  do  with 

digestion  and  assimilation  and 
respiration;  also  the  embry- 
onal bladder  or  allantois  and 
the  primitive  trace  or  spinal 
canal.  So,  for  example,  the 
trachea  and  lungs  come  from 
this  layer,  the  thyroid,  liver, 
stomach,  pancreas  and  bowel. 
The  Trunk  of  the  Body.— 
In  the  centre  of  the  embryo, 
like  the  keel  of  a  boat,  is  a 
plate  or  layer  of  cells  from  the 
ectoderm,  whose  edges  gradu- 
ally turn  upward,  and  finally 
close  to  form  a  tube.  In  these 
are  developed  the  brain  and 
spinal  cord.  Here  gradually 
form  the  vertebrae  and  the 
spinal  column. 

The  Circulation  of  the  Em- 
bryo.—  Nutritious  matter  is 
first  carried  by  transudation 
or  osmosis  from  the  oviduct 
or  Fallopian  tube  into  the  yelk 
substance  of  the  ovum.  This 
goes  on  after  the  embryo  has 
been  covered  by  the  deciduous 
membranes.  The  embryonal 


Fig.  17.— Embryo  of  13  to 
14  days;  1,  mid-brain;  2,  after- 
brain:  3,  cerebellum;  4,  amnion; 
5  and  7,  neural  canal;  6,  primi- 
tive trace;  8,  fore-brain;  9,  oval 
cavity;  10,  heart;  11,  vitelline 
canal;  12,  vitelline  membrane; 

13,  border  of  medullary  plate; 

14,  allantois.     (After  Schultzo.) 


heart  may  be  recognized  in  the 

cervical  region,  and  pulsates  before  the  blood-vessels  develop. 
The  first  fluid  passing  through  the  heart  is  without  cells  and 
clear.  Embryonal  blood  and  blood-vessels  form  in  the  vas- 
cular portion  of  the  yelk  substance  outside  the  embryo.  The 
first  trace  of  blood-vessels  is  seen  in  channels  formed  in  the 


GROWTH  AND  DEVELOPMENT  OF  EMBRYO        53 

yelk  area,  which  gradually  develop  toward  the  heart  and 
become  joined  with  it.  The  first  blood-cells  are  formed 
where  the  vessels  develop,  gradually  finding  their  way  to  the 
heart.  They  are  red  and  nucleated,  but  as  the  fetus  grows 
the  blood  corpuscles  are  formed  without  nuclei.  Tubes  of 
protoplasm  comprise  the  first  blood-vessels,  which  gradually 
separate  into  veins  and  arteries,  the  veins  larger  and  thinner; 


Fig.  18. — Embryo  with  open  membranes,  fifteen  to  eighteen  days;  1, 
Allantois;  2,  parietal  mesoblast;  3,  vitelline  membrane,  yolk;  4.  am- 
nion;  5,  heart  (after  Cost-e). 

the  arteries  smaller  and  thicker.     By  the  end  of  the  third 
month  the  blood  cells  have  lost  their  nuclei. 

The  Wolffian  Body  and  the  Heart.— The  Wolffian  body 
is  by  most  observers  considered  the  embryonal  or  primitive 
kidney.  It  is  formed  of  tubules  from  which  the  kidneys  de- 
velop, and  also  Miiller's  ducts,  from  which  the  female  genital 
organs  are  developed.  Near  the  Wolffian  body  is  an  cle- 


54 


MANUAL   OF   OBSTETRICS 


vated  line  of  cells,  from  which,  in  both  sexes,  germinal 
elements  develop. 

The  heart  has  already  been  described  as  a  simple  tube, 
at  one  end  connected  with  the  arterial  vessels  of  the  embryo, 
and  joined  at  the  other  with  the  venous  channels  in  the  sub- 
stance of  the  yelk. 

The  Allantois. — Before  the  development  of  an  independent 
circulation  in  the  embryo  it  obtains  its  nourishment  from  the 
yelk  by  a  bladder-like  body  or  vesicle, "called  the  allantois. 
The  mode  of  growth  of  this  organ  is  not  clearly  denned,  but 


Fig.  19.- 


-Embryo,  third  month;    1,  Chorion;   2,  amnion;  3,  umbilical 
cord  (after  Schulte). 


from  it  are  formed  the  membranes  which  gradually  surround 
the  fetus,  the  amnion  which  is  next  the  fetus,  and  the  chorion 
which  is  next  the  uterus. 

The  Amnion  and  the  Chorion. — The  amnion  next  the  fetus 
must  be  a  perfectly  smooth  and  delicate  membrane  to  per- 
mit the  free  movement  and  development  of  the  embryo  and 
fetus.  How  the  amnion  forms  is  not  clearly  known.  It 
contains  no  blood  vessels  nor  nerves,  is  transparent,  and 
formed  by  a  network  of  connective  tissue,  with  thin  and 
transparent  epithelial  cells.  It  apparently  permits  the 


GROWTH  AND  DEVELOPMENT  OF  EMBRYO        55 

transudation  or  passage  of  thin  fluid,  called  the  amniotic 
liquid. 

The  chorion  next  the  uterus  comes  from  the  ectoderm  and 
mesoderm  and  at  first  completely  surrounds  the  ovum.  In 
contrast  to  the  amnion,  which  is  thin,  the  chorion  is  thick  and 
roughened  by  projecting  tufts,  called  the  villi.  The  tips  of 
these  villi  enter  the  uterine  deciduous  membrane,  and  nutri- 
tious fluid  passes  through  the  decidua  into  the  villi. 

The  Blood  Vessels. — As  the  blood  vessels  are  spread  upon 
the  red  and  fringed  arches,  known  in  the  fish  as  the  gills,  so 
in  the  human  embryo  the  large  blood  vessels,  the  beginning 
of  the  respiratory  tract,  and  also  the  largest  cervical  nerves, 
are  formed  from  the  branchial  arches.  From  these  we  may 
gradually  recognize  the  curved  form  of  the  arch  of  the  aorta 
and  other  great  vessels.  While  the  large  vessels  are  develop- 
ing, capillaries  are  forming  among  the  embryonal  cells  which 
communicate  with  the  venous  extremity  of  the  embryonal 
heart. 

The  First  Distinct  Circulation. — So  soon  as  the  chorion  is 
fully  formed  and  surrounds  the  ovum,  it  is  termed  the  cho- 
rionic  vesicle.  Fluid  accumulates  within  it,  called  the  cho- 
rionic  fluid.  It  is  at  first  rich  in  vessels,  receiving  blood 
through  the  allantois  from  the  embryo  by  two  arteries — af- 
terwards called  the  umbilical  arteries — the  blood  returning 
through  two  umbilical  veins.  This  is  the  embryonal  circu- 
lation through  the  vessels,  and  marks  a  further  step  in  de- 
velopment from  the  primitive  embryonal  circulation  already 
described.  The  villi  grow  very  luxuriantly  until  the  embryo 
develops  into  the  fetus,  when  most  of  the  villi  disappear, 
those  remaining  forming  the  placenta. 

The  Syncytium. — The  villi  of  the  chorion  when  closely 
studied  are  found  to  be  covered  with  a  layer  of  protoplasm 
with  nuclei.  This  layer  is  called  the  syncytium  and  is  of 
epithelial,  or  fetal  origin.  When  the  embryo  forms  the 
placenta,  at  about  four  months,  a  second  layer  of  large  cells 
with  nuclei  can  be  made  out  under  the  syncytium  of  the  villi. 
This  is  also  fetal  tissue,  known  as  Langhans'  layer.  During 
embryonal  life  the  syncytium  grows  abundantly.  The  villi  of 
the  chorion  bud  and  proliferate  and  project  into  the  sinuses 
in  the  wall  of  the  uterus.  The  capillaries  of  the  villi  are 


56 


MANUAL   OF   OBSTETRICS 


under  the  epithelial  cells  of  the  villi  and  the  capillary  walls 
are  formed  by  a  single  layer  of  endothelium.  As  the  villi 
project  into  the  mother's  blood-channels  there  is,  in  the  cap- 
illaries, a  layer  of  endothelium  and  one  of  epithelium  in  the 
mother's  tissues,  between  the  fetal  and  maternal  blood.  It  is 
obvious  that  a  gas,  such  as  oxygen,  or  very  soluble  substance, 


Fig.  20. — Section  through  pregnant  uterus:  U,  Uterus;  Fb,  tube; 
UH,  cavity  of  uterus;  Dv,  decidua  vera  which  joins  uterine  placenta 
at  Pu;  Dr,  decidua  reflexa;  Pf,  fetal  portion  of  placenta;  Chi,  chorion 
Iseve;  A,  amniotic  cavity  filled  with  fluid;  H,  heart  of  embryo;  Ci, 
and  Cs,  inferior  and  superior  vena  cava;  At,  artery  allantois,  umbilical 
artery;  D,  rudimentary  allantois. 

can  pass  from  the  blood  of  the  mother  into  that  of  the  em- 
bryo and  fetus.  The  villi  of  the  chorion  with  connective 
tissue  and  cells  from  the  lining  membrane  of  the  uterus  ulti- 
mately develop  into  the  placenta. 

The  Embryo  at  Different  Periods. — At  the  end  of  three  or 
four  weeks  the  embryo  is  enclosed  in  the  chorionic  vesicle. 


THE    FETUS  57 

It  is  curved  considerably  upon  itself,  a  faint  outline  of  the 
head  can  be  made  out,  the  neck  is  strongly  bent,  and  the 
pedicle  of  the  allantois  is  developing  into  the  umbilical  cord. 
By  the  end  of  the  first  month  the  body  of  the  embryo  can  be 
plainly  discerned  and  the  rudimentary  limbs  are  becoming 
longer;  a  faint  outline  of  the  human  being  can  be  made  out 
in  thirty-eight  days;  at  fifty  days  the  chin,  nose  and  mouth 
can  be  plainly  seen;  the  fingers  are  well  developed,  and  the 
toes  are  beginning  to  lose  their  webbed  condition.  At  two 
months,  or  sixty  days,  both  feet  are  turned  inward,  the  toes 
can  be  distinctly  made  out,  and  the  arms  and  hands  are  di- 
rected upward  toward  the  face.  At  seventy-five  days  the 
fetus  can  be  recognized  in  the  shape  of  a  young  child,  its 
slender  body,  disproportionately  large  head,  and  the  begin- 
ning of  the  nails,  can  be  discerned.  At  three  or  four  months, 
when  most  abortions  occur,  the  eyelids  of  the  fetus  are  closed, 
the  chin  is  pointed,  the  nose  and  lips  distinct,  and  the  general 
bending  of  the  body,  known  as  flexion,  has  begun. 

tTHE  FETUS 

The  embryo  ceases  to  be  so  called  as  the  placenta  forms 
between  the  third  and  fourth  months.  From  this  time  the 
new  being  is  styled  the  fetus. 

The  Size  and  Weight  of  the  Fetus. — The  average  weight 
at  the  third  month  is  11  grammes;  at  the  fourth  month  57 
grammes;  the  fifth  month  284  grammes;  the  sixth  month 
634  grammes;  the  seventh  month  1218  grammes;  at  the 
eighth  month  1569  grammes;  at  the  ninth  month  1971 
grammes. 

The  length  may  be  obtained  by  Diihrssen's  rule,  namely, 
to  multiply  the  month  by  itself  until  one  comes  to  the  fifth 
month;  after  this,  one  continues  to  multiply  the  month  by 
five.  Thus  at  the  end  of  one  month  the  embryo  is  1  cm. 
long,  or  4.9  of  an  inch;  at  the  end  of  the  second  month  4 
cm.,  or  li  inches;  at  the  end  of  the  third  month  9  cm. 
long,  or  4  inches;  at  the  end  of  the  fourth  month  16  cm. 
long,  or  7^  inches;  at  the  end  of  the  fifth  month  25  cm. 
long,  or  UTT  inches;  at  the  end  of  the  sixth  month  30  cm. 
long,  or  13.|  inches;  at  the  end  of  the  seventh  month  35 


58  MANUAL   OF   OBSTETRICS 

cm.  long,  or  15f  inches;  at  the  end  of  the  eighth  month  40 
cm.  long,  or  I?T  inches;  at  the  end  of  the  ninth  month  45 
cm.  long,  or  20  inches;  and  at  the  completion  of  pregnancy, 
its  fullest  term,  50  cm.,  or  22|  inches. 

To  obtain  the  fetal  length,  the  rule  usually  followed  is  to 
square  the  month  of  pregnancy  up  to  the  fifth;  after  that 
multiply  the  month  by  five. 

Variations  in  Fetal  Weight. — Many  things  influence  the 
weight  of  the  fetus.  Abundant  food  for  the  mothenor  starva- 
tion, heavy  and  exhausting  work,  great  mental  anxiety,  and 
in  general,  anything  which  depresses  the  mother  and  deprives 
her  of  strength,  lessens  the  weight  of  the  child.  At  between 
30  and  35  years,  the  mother  produces  the  largest  children  and 
the  best  developed.  There  seems  to  be  some  relation  be- 
tween the  height  and  weight  of  the  mother  in  the  size  of  the 
child.  Where  the  conditions  for  healthy  children  are  good, 
the  weight  of  the  fetus  increases  with  successive  pregnancies; 
thus  the  fourth  or  fifth  child  might  be  from  2  to  5  Ibs.  heavier 
than  the  first  child.  The  fetus  grows  most  actively  in  weight 
from  the  fourth  to  the  fifth  month,  when  the  weight  should 
increase  four-fold.  This  is  when  the  placenta  fully  develops 
and  the  size  of  the  placenta  is  in  proportion  with  the  child. 

The  Full-term  Fetus. — It  is  often  interesting  and  important 
to  be  able  to  state  that  a  child  is  born  at  full  term.  This  can 
best  be  ascertained  by  taking  its  full  length  and  by  the  pro- 
portions which  exist  between  the  various  parts  of  its  body. 
Thus  if  the  fetus  at  full  term  measures  normally  50  cm.,  one- 
half  of  this  plus  10,  equals  35  cm.,  which  will  be  the  circum- 
ference of  the  chest  at  the  region  of  the  nipples.  The  head 
will  be  larger  than  the  chest,  the  circumference  of  the  cra- 
nium being  37  to  38  cm.  When  these  proportions  fail,  or  are 
reversed,  the  fetus  is  not  at  full  term,  or  has  been  stunted  by 
some  disease  or  accident.  At  term  the  measurement  around 
the  fetal  shoulders  just  below  the  acromial  processes,  should 
be  fully  32  cm.  A  child  born  of  healthy  parents  should  not 
weigh  less  than  6  Ibs.  at  birth.  One  can  also  judge  concern- 
ing the  development  of  the  child  by  its  plumpness  and  firm- 
ness, by  the  color  and  bright  appearance  of  the  eyes,  and  the 
vigor  of  its  movements  and  cry,  and  by  the  strength  and 
rhythm  of  the  action  of  the  heart. 


THE    FETUS  59 

It  is  difficult  to  tell  exactly  when  the  fetus  is  viable,  but  a 
fetus  26  weeks  old  has  grown  and  lived.  As  an  aid  in  es- 
timating the  growth  of  the  fetus,  the  size  of  the  mother's 
uterus  at  different  periods  of  pregnancy,  is  of  great  value. 

The  development  of  the  child  may  be  divided  into  three 
periods:  The  first  four  months  devoted  to  the  growth  of  the 
various  layers  of  cells  forming  the  embryo  and  the  organs 
derived  from  them,  and  these  may  be  styled  the  period  of 
development.  The  essential  portions  of  the  child  are  fully 
formed  at  the  close  of  embryonal  life. 

The  next  period  from  the  fourth  to  the  seventh  month,  is 
the  time  of  growth,  when  the  fetus  increases  rapidly  hi  size. 

From  viability  at  about  the  seventh  month  to  birth  at 
full  term,  the  fetus  does  not  grow  so  much  in  length  as  in 
weight,  and  this  may  be  termed  the  period  of  ripening. 

The  Fetal  Circulation. — This  somewhat  difficult  subject 
may  perhaps  be  best  understood  if  one  follows  the  blood  from 
the  placenta  through  the  umbilical  vein  which  contains  oxy- 
genated blood,  entering  the  body  at  the  navel  or  umbilicus, 
and  running  from  thence  to  the  posterior  border  of  the  liver. 
Here  it  meets  the  hepatic  portal  vein,  bringing  blood  from  the 
bowel  of  the  fetus.  Reaching  the  liver,  a  portion  of  the 
blood  goes  through  the  afferent  hepatic  vessels  into  the  liver, 
and  through  the  hepatic  veins  to  the  posterior  vena  cava. 
The  greater  part  of  the  blood  passes  through  the  wide  ductus 
venosus  into  the  posterior  vena  cava  without  going  through 
the  liver,  and  thus  reaches  the  heart.  This  blood  contains 
more  nutritious  matter  and  more  oxygen  than  the  blood  re- 
turned by  the  anterior  vena  cava,  and  also  has  less  nitrogen- 
ous waste  material  from  the  fetus.  It  is  practically  arterial 
blood.  This  blood  through  the  posterior  vena  cava  does  not 
enter  the  right  auricle,  but  passes  by  the  Eustachian  valve 
through  the  foramen  ovale  into  the  left  auricle,  and  here  it 
receives  a  very  small  quantity  of  blood  coming  through  the 
pulmonary  veins  from  the  unexpanded  fetal  lungs.  From 
the  left  auricle  the  blood  passes  into  the  ventricle,  thence 
through  the  aorta  into  the  carotids  and  subclavians  to  the 
heart  and  arms.  The  blood  pressure  in  the  fetal  circulation 
is  such  that  but  very  little  of  this  blood  enters  the  dorsal  por- 
tion of  the  aorta,  for  this  vessel  already  contains  blood  from 


60  MANUAL   OF    OBSTETRICS 

the  right  ventricle  through  the  ductus  arteriosus.  The  walls 
of  the  two  ventricles,  equal  in  strength  and  thickness,  force 
the  blood  from  the  right  ventricle  along  the  aortic  arch, 
while  the  blood  from  the  left  ventricle  is  carried  backward 
along  the  dorsal  aorta,  thence  descending  it  passes  to  the  lower 
limbs  and  nourishes  the  inferior  portion  of  the  fetal  body. 

As  the  fetal  lungs  are  not  unfolded,  and  as  respiration  has 
not  occurred,  the  right  ventricle  of  the  heart  and  dark  blood 
passing  thence  through  the  pulmonary  trunk,  passes  in  small 
portion  only  to  the  tissues  of  the  lungs.  The  greater  part  of 
the  venous  blood  from  the  right  heart  passes  through  the 
ductus  arteriosus  to  the  aorta  and  down  to  the  common  ili- 
acs  to  the  lower  extremities,  and  thence  through  the  umbil- 
ical or  allantoic  arteries  to  the  placenta, where  it  receives  oxy- 
gen and  nutritious  matter,  and  returns  through  the  umbilical 
or  allantoic  vein.  The  ductus  arteriosus  is  a  channel  which 
prevents  the  greater  part  of  the  blood  from  passing  to  the 
lungs,  where  it  is  not  needed,  and  carries  it  into  the  aorta; 
while  the  ductus  venosus  conveys  the  pure  blood  from  the 
placenta  into  the  posterior  vena  cava  without  passing  through 
the  liver.  In  the  fetus  the  right  auricle  receives  blood  from 
the  anterior  vena  cava,  the  coronary  sinuses,  and  the  poste- 
rior vena  cava;  the  left  auricle  by  the  Eustachian  valve,  from 
the  foramen  ovale,  receives  the  blood  from  the  posterior  vena 
cava;  the  anterior  vena  cava  brings  from  the  head  and  arms 
the  venous  blood;  the  posterior  vena  cava  the  blood  from  the 
posterior  part  of  the  body,  the  lower  limbs  and  kidneys,  and 
also  from  the  placenta,  intestine  and  liver. 

The  fetal  circulation  cannot  be  understood  without  re- 
membering that  while  the  fetus  is  within  the  uterus  and  the 
placenta  is  attached  to  the  mother's  uterus,  that  the  func- 
tions of  oxygenation  and  respiration,  as  performed  by  the 
lungs,  and  the  changes  in  the  blood  normally  performed  by 
the  liver,  are  reduced  to  their  lowest  terms  during  intra- 
uterine  life.  The  mother  breathes  and  assimilates  for  the 
fetus  by  means  of  the  placenta;  hence  the  blood  from  the 
placenta  is  sent  in  very  small  portion  only  to  the  liver  and 
to  the  lungs,  and  the  two  channels  provided  for  this  purpose 
are  respectively  the  ductus  venosus  and  the  ductus  arteriosus. 

It  is  obvious  that  if  the  aorta  was  to  be  obliterated  just  in 


THE    FETUS  61 

front  of  the  point  where  the  ductus  arteriosus  enters,  that 
the  fetus  could  live  until  it  was  separated  from  the  mother; 
then  its  further  existence  would  become  impossible. 

The  Changes  hi  the  Fetal  Circulation  at  Birth. — The  ex- 
pulsion of  the  child  from  the  uterus,  so  long  as  the  placenta 
remains  attached,  does  not  greatly  alter  its  fetal  conditions. 
It  frequently  breathes  but  very  little  until  the  placenta  sepa- 
rates and  the  lungs  gradually  expand.  When  this  occurs 
the  placental  circulation  ceases,  the  vessels  in  the  umbilical 
cord  become  plugged,  the  lungs  open,  blood  passes  freely  into 
them,  the  Eustachian  valve  is  gradually  pushed  against  the 
foramen  ovale  and  closes  it,  and  the  ductus  arteriosus  and 
ductus  venosus  are  closed  and  gradually  shrink,  while  the 
umbilical  arteries  or  allantoic  vessels  are  gradually  obliter- 
ated. These  changes  cause  the  blood  from  the  anterior  and 
posterior  vena  cavae  to  pass  from  the  right  auricle  to  the  right 
ventricle,  thence  as  the  ductus  arteriosus  is  closed  when  the 
right  ventricle  contracts,  the  blood  cannot  enter  the  aorta 
but  passes  along  the  pulmonary  arteries  to  the  lungs.  From 
the  lungs  it  enters  the  left  auricle  from  the  pulmonary  veins, 
thence  to  the  left  ventricle,  which  forces  it,  as  in  the  adult, 
to  the  head  of  the  upper  and  lower  extremities. 

The  shutting  off  of  the  ductus  venosus  sends  the  blood 
in  the  hepatic  region  through  the  capillaries  of  the  liver  to 
the  posterior  vena  cava.  The  closing  of  the  two  ducts  and 
of  the  foramen  ovale  changes  the  circulation  of  the  fetus  to 
that  of  the  adult  individual.  This  process  is  gradual,  occupy- 
ing from  ten  days  to  three  weeks,  the  allantoic  or  umbilical 
arteries  first  becoming  occluded,  then  the  umbilical  veins  and 
ductus  venosus  with  the  ductus  arteriosus. 

The  most  important  of  all  changes,  so  far  as  the  health 
of  the  child  is  concerned,  is  the  closure  of  the  foramen  ovale. 
At  first  the  edges  of  the  valve  are  kept  closely  applied  to  the 
margins  of  the  opening  by  blood  pressure.  Later  the  valve 
seems  to  adhere  or  grow  into  the  septum  of  the  heart.  Should 
this  junction  be  imperfect,  venous  and  arterial  blood  will 
mix,  the  color  of  the  child  will  be  partly  cyanotic,  and  the 
baby  is  often  called  a  blue  baby.  Such  a  child  develops 
feebly  and  is  always  in  danger  of  death  through  engorge- 
ment of  the  lungs  and  overdistention  of  the  heart. 


62 


MANUAL   OF   OBSTETRICS 


THE  FETAL  APPENDAGES 

The  Umbilical  Cord. — The  beginning  of  this  cord,  which 
connects  the  fetus  with  the  placenta,  is  found  in  the  stalk  of 
the  allantois.  This  sac — the  allantois — is  a  diverticulum 
or  offshoot  from  the  embryo.  The  cord  is  not  covered  by 
amnion,  which  develops  at  the  sides  of  the  umbilical  cord 
but  does  not  extend  upon  its  surface.  If  the  stalk  of  the 
allantois  be  cut  across  it  is  seen  to  consist  of  connective  tissue 
with  branching  cells  derived  from  the  ectoderm  and  meso- 
derm.  Its  blood  vessels  become  more  or  less  thick  by  the 
growth  of  cells  lining  their  walls.  At  full  term  the  cord  is 

twisted  in  spirals  from 
left  to  right,  whitish  in 
color  because  of  the 
presence  of  embryon- 
ic connective  tissue, 
called  Wharton's  jelly, 
and  varying  greatly  in 
length.  It  is  narrow- 
est at  the  fetal  end 
where  the  epidermis  of 
the  fetus  grows  upon 
the  cord  for  a  short 
distance.  It  joins  the 
chorion  at  the  pla- 
centa. Where  the 
cord  terminates  out- 
side the  centre  of  the 

afterbirth  it  becomes  united  with  the  chorion,  forming  a  mem- 
branous insertion,  called  velamentous.  The  external  surface 
of  the  cord  is  covered  with  epithelium,  which  is  continuous 
with  the  amnion,  and  which  covers  Wharton's  jelly.  When 
the  fetus  is  developed  it  contains  two  arteries,  the  umbilical 
and  one  large  vein  in  the  centre,  the  umbilical  vein.  The 
cord  is  without  nerves,  lymphatics  or  capillaries,  and  the 
arteries  contain  no  elastic  tissue,  but  muscular  tissue  and 
intima  lining.  There  seems  to  be  no  explanation  for  the 
varying  length  in  the  cord,  nor  for  the  different  quantity 
of  Wharton's  jelly  often  found;  thus  some  cords  are  so  thick 


Fig.  21. — Cross-section  of  umbilical 
cord  at  term:  1,  umbilical  vein;  2,  um- 
bilical arteries. 


THE    FETAL   APPENDAGES  63 

that  they  are  tied  with  difficulty,  because  of  the  great  quan- 
tity of  Wharton's  jelly  present,  and  in  some  cases  this  must 
be  pressed  out  from  the  cut  end  before  a  ligature  will  hold. 
As  the  arteries  possess  a  thick  muscular  coat  they  must  be 
firmly  tied  to  be  completely  closed.  If  this  be  not  done  the 
ligature  may  slip,  and  hemorrhage,  dangerous  or  fatal  to  the 
fetus,  may  result.  The  cord  is  peculiar  in  that  oxygenated 
blood  is  carried  from  the  placenta  in  the  umbilical  vein, 
while  impure  blood  containing  the  waste  material  of  the  fetus 
is  carried  in  the  two  umbilical  arteries. 

The  Placenta. — The  placenta  or  afterbirth  is  called  in 
Germany,  the  mother-cake  or  Mutter-kuchen.  It  is  ordina- 
rily as  large  as  a  large  saucer  or  tea-plate.  It  is  from  half  an 
inch  to  an  inch  and  a  half  thick,  resembling  raw  meat  in 
color,  and  divided  into  small  lobes  or  portions,  called  cotyle- 
dons. It  varies  in  size  with  the  development  of  the  child. 
At  its  edges  it  grows  thin,  joining  with  the  amnion  and 
chorion,  which  are  attached  around  the  edge  of  the  placenta. 
These  membranes  form  a  bag  containing  the  fetus  and  the 
amniotic  liquid. 

If  one  examines  the  placenta  closely  between  the  cotyle- 
dons there  will  be  seen  areas  of  flesh-colored  or  pale  yellow. 
These  are  the  villi  which  can  be  seen  through  the  chorion. 
At  the  placenta  the  blood  vessels  of  the  cord  divide  mi- 
nutely, the  arteries  remaining  on  the  surface,  and  the  veins 
going  more  deeply  but  without  anastomosis.  On  the  uterine 
surface  of  the  placenta  can  be  demonstrated  a  soft  membrane, 
light-grayish  in  color — the  placental  decidua  or  decidua 
serotina.  At  childbirth  this  is  divided  into  two  parts.  If 
the  placenta  be  examined  in  sections,  it  contains  masses  of 
twigs  or  branches  which  grow  out  of  the  chorion  and  are  de- 
veloped from  its  villi.  The  spaces  between  the  villi  form  the 
blood  channels  of  the  placenta,  into  which  open  the  arteries 
and  veins  of  the  placenta. 

The  placenta  is  applied  to  the  wall  of  the  uterus  but  is 
rarely  if  ever  adherent.  It  follows  the  wall  of  the  uterus 
when  the  womb  contracts,  as  it  is  convex,  being  fixed  in  the 
centre  and  growing  thin  toward  the  edges.  The  placenta  is 
applied  to  the  wall  of  the  uterus  by  the  pressure  of  the  amni- 
otic liquid  and  by  the  property  possessed  by  living  membrane 


64  MANUAL    OF    OBSTETRICS 

of  adhering  to  other  living  tissues.  The  placenta  is  often 
said  erroneously  to  be  adherent,  but  such  is  never  the  case 
unless  some  pathological  process  has  changed  the  uterine 
decidua  and  the  placental  decidua  as  well. 

The  Circulation  of  the  Placenta. — How  nourishment  passes 
from  mother  to  child  in  the  placenta  is  not  known.  There  is 
no  evidence  that  the  circulation  of  the  mother  and  child  con- 
nect directly.  The  process  seems  one  of  osmosis  or  the  pas- 
sage through  a  membrane,  and  the  spaces  between  the  villi 
are  undoubtedly  from  the  first  development  of  the  embryo 
the  channels  for  the  mother's  blood.  By  some  it  is  held  that 
material  passes  from  mother  to  fetus  by  the  transfer  of  masses 
of  leukocytes  in  the  channels  of  the  placenta. 

The  uterine  decidua  gradually  disappears  as  pregnancy  ad- 
vances, thus  bringing  the  placental  villi  into  close  relation 
with  the  mother's  blood  channels.  The  fetal  membrane 
joins  with  the  connective  tissue  in  the  uterus  and  derives 
nourishment  from  the  uterine  capillaries. 

The  placenta  has  been  termed  by  some  the  gill  of  the  fetus, 
as  it  permits  the  oxygenation  of  its  blood  as  the  red  fringes 
in  the  gill  of  a  fish  are  formed  by  the  small  blood  vessels  of 
the  fish.  It  is  evident  that  if  the  substance  of  the  placenta 
be  altered  by  disease  that  the  oxygenation  of  the  fetal  blood 
will  suffer,  and  hence  those  diseases  which  greatly  alter  the 
tissues  of  the  placenta  result  in  fetal  death.  As  the  stem  of 
an  apple  undergoes  changes  when  the  fruit  is  ripe,  so  the 
human  placenta  is  altered  as  pregnancy  draws  toward  its 
close.  Whitish  deposits  are  seen  throughout  the  placenta 
in  some  cases  where  the  excretion  of  the  mother  is  greatly 
altered.  This  destroys  the  circulation  of  the  mother  at  that 
point  and  may  indirectly  cause  the  death  of  the  fetus  through 
asphyxiation.  So  syphilis,  which  causes  changes  in  the 
placenta,  frequently  destroys  fetal  life.  There  is  evidence 
that  soluble  substances  pass  from  mother  to  child  through 
the  placenta  and  that  bacteria  may  also  reach  the  fetus 
through  the  mother's  circulation.  The  cells  of  the  placenta 
have  also  the  function  of  forming  complex  albuminoid  sub- 
stances, some  of  which  act  as  antibodies  against  diseased  prod- 
ucts coming  from  the  fetus.  The  placenta  then  is  not  sim- 
ply an  organ  for  oxidation,  but  also  an  organ  of  assimilation, 
playing  an  important  part  in  fetal  and  maternal  metabolism. 


PART   II 
PREGNANCY 


CHAPTER  VI 
PREGNANCY 

As  the  fetus  grows  it  assumes  relation  to  the  body  of  the 
mother.  In  early  pregnancy  when  the  uterine  cavity  is 
globular  the  fetus  moves  freely  in  all  directions.  As  it  in- 
creases in  size  the  uterus  loses  its  globular  form,  becoming 
lengthened,  and  the  movements  of  the  child  are  restricted. 


Fig.  22.— Flexion.  Fig.  23.— Extension. 

Probably  by  the  force  of  gravity  the  heaviest  portion  of 
the  fetus  is  usually  lowest  in  the  uterus  and  comes  to  the  in- 
ternal os.  The  long  axis  of  the  fetus  coincides  with  the  long 
axis  of  the  womb.  That  portion  of  the  fetus  which  presents 
at  the  mouth  of  the  uterus  is  naturally  called  the  presenting 
part,  and  its  location  brings  about  what  is  known  as  presen- 
5  65 


66 


MANUAL   OF   OBSTETRICS 


tation.  Presentations  are  named  in  accordance  with  the 
fetal  part  which  presents,  thus,  there  are,  when  the  head 
is  lowest,  vertex,  brow  and  face  presentations  of  the  head. 
As  the  long  axis  of  the  fetus  must  correspond  with  the  long 
axis  of  the  uterus,  the  breech  or  inferior  extremity  of  the 
fetus  may  in  some  cases  present. 

If  the  fetus  be   turned   transversely  across  the  womb, 
the  shoulder  presents. 


Fig.  24. — First  position,  vertex. 

It  must  be  remembered  that  presentation  applies  to  the 
fetus  and  not  to  the  mother. 

Position. — The  relation  which  the  fetus  bears  to  the  mother 
is  called  its  position.  Under  ordinary  circumstances  the 
head  of  the  child  being  lowest  and  presenting,  its  back  is 
directed  toward  the  left  side  of  the  mother's  abdomen.  This 
is  termed  the  first  position.  When  this  is  present  the  head 
may  present  or  the  breech  may  present,  but  position  applies 


PREGNANCY 


67 


to  the  relation  between  the  body  of  the  fetus  and  the  mother. 
Less  often  the  back  is  turned  toward  the  right  side  of  the 
mother,  when  a  second  position  of  either  head  or  breech  may 
be  present. 

Occasionally  abnormal  positions  and  presentations  de- 
velop. Thus  the  child  may  be  across  the  mother's  womb, 
the  shoulder  presenting,  or  the  child  may  be  oblique  in  the 
mother's  womb  and  the  brow  presenting.  There  are  also 


Fig.  25. — The  head  engaging  and  descending, 
presentation. 


Second  position  vertex 


complex  presentations  where  one  or  both  arms  may  be  in. 
front  of  the  child's  head,  or  where  the  legs  may  present  in 
front  of  the  breech. 

Engagement. — The  term  engagement  has  to  do  with  the 
entrance  of  the  fetus  into  the  mother's  birth-canal.  As  the 
purpose  of  pregnancy  is  to  give  birth  to  a  living  child,  and 
the  child  must  pass  through  the  pelvis  to  be  born,  the  ques- 
tion of  engagement  becomes  of  great  importance.  The  pre- 


68  MANUAL   OF   OBSTETRICS 

senting  part,  whether  head  or  breech,  is  said  to  engage 
when  it  enters  the  pelvis.  It  must  not  only  be  in  the  pelvic 
brim,  but  descend  through  the  brim  to  the  cavity  of  the  pelvis 
to  really  engage.  As  this  is  one  of  the  most  important  con- 
ditions in  the  development  of  labor  it  is  obviously  essential 
that  a  physician  should  be  able  to  recognize  if  engagement 
has  taken  place.  If  engagement  does  not  develop  at  the 
beginning  of  labor,  then  naturally  birth  is  impossible.  There 
is  some  abnormality  present  and  interference  and  often  op- 
eration becomes  necessary.  If  the  physician  attempts  to 
drag  the  child  down  into  the  pelvis,  and  through  the  pelvis, 
without  engagement,  the  death  of  the  child  frequently  fol- 
lows. Such  deliveries  are  accompanied  by  considerable  in- 
jury to  the  mother. 

If  the  fetus  be  turned  across  the  uterus  and  pelvis  it  is  evi- 
dent that  no  true  engagement  can  develop.  The  fetus  may 
be  wedged  into  the  pelvic  brim,  but  it  cannot  pass  through. 
It  is  then  said  to  be  impacted. 


CHAPTER  VII 
THE  DIAGNOSIS  OF  PREGNANCY 

No  subject  in  medicine  is  more  difficult  in  some  cases,  and 
more  important,  than  the  diagnosis  of  pregnancy.  If  preg- 
nancy be  present  and  it  be  not  discovered,  the  patient  may 
be  operated  upon  for  some  condition  which  is  supposed  to 
be  present,  but  which  is  absent,  or  may  be  treated  for  some 
disease  which  she  does  not  have.  Thus,  the  abdomen  has 
been  opened  supposedly  for  a  fibroid  tumor  of  the  uterus 
when  pregnancy  was  present,  and  patients  have  been  treated 
for  gastritis  when  this  condition  was  not  present  but  when  the 
patient  was  pregnant.  Such  errors  in  diagnosis  may  injure 
the  reputation  of  the  physician  and  also  that  of  the  patient. 
Unmarried  women  may  be  suspected  wrongfully  of  illegiti- 
mate pregnancy,  and  by  a  false  diagnosis  such  women  may 
be  subjected  to  operation  and  the  pregnancy  discovered  and 
made  public  by  the  operation.  In  the  case  of  married  women 
unnecessary  operation  or  improper  treatment  may  cause 
abortion  if  pregnancy  is  not  recognized.  Most  mistakes  in 
the  diagnosis  of  pregnancy  occur  because  the  physician  does 
not  follow  a  systematic  plan  in  studying  the  case.  It  is 
important  that  the  student  should  recognize  this  fact  and 
that  he  should  examine  his  patients  by  a  uniform  method. 

THE  HISTORY  OF  PREGNANCY 

It  is  usual  in  diagnosticating  disease  to  first  obtain  the 
statements  of  the  patient  or  of  those  who  know  concerning 
her  health.  When  normal  pregnancy  is  present  the  patient 
will  state  that  menstruation  has  entirely  ceased  or  has  be- 
come greatly  lessened.  In  a  patient  who  has  always  been 
regular  this  fact  is  of  considerable  importance.  Next  often 
the  patient  will  describe  disturbance  of  the  stomach,  more  or 
less  severe.  This  will  usually  be  said  to  occur  on  waking  in 

*69 


70  MANUAL   OF  OBSTETRICS 

the  morning,  often  not  returning  during  the  day.  There  is  a 
desire  to  empty  the  stomach,  and  a  varying  quantity  of  sour 
or  acrid  mucus  and  fluid  is  ejected. 

In  addition  to  the  cessation  of  menstruation  and  disturb- 
ance of  the  stomach  the  patient  will  describe  disturbance 
in  the  skin,  and  especially  in  the  mammary  glands.  The 
breasts  will  be  said  to  be  enlarged  and  unusually  tender  with 
shooting  or  pricking  sensations  through  them.  The  nipples 
may  be  unusually  sore,  and  pressure  of  clothing  may  give  the 
patient  considerable  annoyance.  As  pregnancy  proceeds 
it  will  be  noticed  that  the  abdomen  is  growing  large,  that  the 
functions  of  the  bladder  are  disturbed,  and  that  the  bladder 
must  be  emptied  more  frequently  than  usual.  Constipa- 
tion sometimes  is  reported,  and  occasionally  diarrhea.  Loss 
or  increase  of  appetite,  and  improvement  in  the  general  health 
or  considerable  disturbance,  are  commonly  noted. 

At  about  the  fourth  month  of  pregnancy  the  patient  will 
describe  the  first  movements  of  the  fetus.  This  sensation  is 
usually  compared  to  the  fluttering  of  a  young  bird  in  the 
hand.  As  the  fetus  grows  its  movements  will  become  more 
distinct  and  vigorous,  until  at  full  term  they  may  be  suffi- 
ciently strong  to  give  the  mother  considerable  pain.  The 
mother  may  also  complain  of  a  whitish  vaginal  discharge. 

While  this  is  a  history  of  normal  pregnancy,  it  must  not 
be  forgotten  that  all  these  symptoms  may  be  described  by 
a  patient  who  is  not  really  pregnant.  In  the  condition  known 
as  false  pregnancy,  or  pseudocyesis,  the  sensations  experi- 
enced in  pregnancy  are  present,  but  they  arise  from  a  disor- 
dered nervous  condition  and  not  from  actual  gestation. 

In  studying  cases  the  history  should  always  be  obtained 
first  from  the  patient.  It  should  at  least  put  the  physician 
on  his  guard  as  to  the  existence  of  pregnancy.  It  often  re- 
lieves the  patient's  embarrassment  if  she  describes  her  symp- 
toms, and  this  narration  gives  the  physician  an  opportunity 
as  he  listens  to  the  history  to  observe  the  patient  carefully. 
Occasionally  the  symptoms  of  pregnancy  are  accurately  de- 
scribed by  a  woman  who  is  not  pregnant,  but  who  is  vicious 
and  who  attempts  blackmail. 

On  the  other  hand,  the  patient  may  not  suspect  the  preg- 
nancy, and  may  in  good  faith  describe  symptoms  of  preg- 


PHYSICAL   EXAMINATION   IN   DIAGNOSIS    OF   PREGNANCY   71 

nancy  which  to  her  indicate  some  diseased  and  abnormal 
condition.  In  such  cases  the  physician  must  receive  the 
history  attentively,  and  as  symptoms  of  pregnancy  are  dis- 
closed he  must,  while  accepting  the  history,  make  no  diag- 
nosis until  he  has  made  a  physical  examination.  In  studying 
a  case  of  pregnancy  the  history  should  be  noted,  record  being 
made  of  the  last  menstruation  and  its  duration,  and  the  time 
when  life  was  felt,  if  such  has  been  the  case.  It  is  important 
in  obtaining  the  date  of  the  last  menstruation  to  know 
whether  this  period  was  a  perfectly  normal  one.  If  it  oc- 
curred at  the  usual  time  and  was  considerably  less  in  quantity, 
conception  may  have  occurred  just  before  this  period.  These 
salient  facts  concerning  the  case  should  be  kept  on  record. 

PHYSICAL    EXAMINATION    IN    THE    DIAGNOSIS    OF    PREG- 
NANCY 

Before  proceeding  to  examine  the  generative  organs  a 
general  physical  examination  of  the  patient  should  be  made. 
The  condition  of  the  face  and  eyes  should  be  noted,  as  the 
face  may  be  flushed  or  discolored  if  pregnancy  is  present;  so 
the  condition  of  the  eyes  is  important,  as  pregnancy  is  some- 
times complicated  by  exophthalmic  goitre.  The  thyroid 
gland  must  be  palpated.  Very  commonly  the  thyroid  is  en- 
larged moderately  in  early  pregnancy,  and  this  condition 
has  by  some  been  thought  to  be  a  sign  of  clinical  value. 

In  examining  the  chest  the  mammary  glands  should  be 
inspected.  If  pregnancy  is  present  in  primiparous  patients 
they  will  be  enlarged  after  the  first  few  weeks,  tender  to  pal- 
pation, and  around  the  nipple  will  be  a  circular  area  of  more 
or  less  pigmented  tissue.  In  blonde  patients  the  discolora- 
tion is  slight,  and  in  brunettes  it  is  very  pronounced.  Small 
follicles  surrounding  the  nipples  will  be  enlarged  and  dis- 
tinctly raised  above  the  surface.  The  nipple  itself  will  be 
somewhat  darker  and  sensitive.  Sometimes  the  lymphatic 
glands  in  the  axillae  are  also  enlarged.  Gentle  pressure  upon 
the  breasts  will  frequently  cause  fluid  to  issue  from  the 
nipples. 

On  listening  to  the  heart  it  will  be  noticed  that  its  action 
is  unusually  disturbed  and  that  the  circulation  is  very  sen- 
sitive to  excitement.  In  anemic  patients  indistinct  mur- 


72  MANUAL    OF    OBSTETRICS 

murs  are  often  heard  over  the  heart.  The  examination  of 
the  abdomen  is  important  because  it  may  reveal  the  enlarged 
uterus.  This  is  rarely  felt  before  the  fourth  month  unless 
the  abdominal  wall  is  unusually  thin  and  elastic.  At  the 
fourth  month  the  uterus  is  a  globular  tumor  extending  slightly 
above  the  pubis.  Pressure  on  each  side  of  the  uterus  may 
elicit  pain  because  the  ovaries  are  often  unusually  tender. 
If  the  abdomen  be  inspected  in  the  later  months  of  preg- 
nancy the  abdominal  tumor  is  evident,  and  in  the  last  months 
the  abdomen  may  be  pigmented,  and  the  white  and  some- 
what shining  stripes  upon  the  abdomen  caused  by  the  separa- 
tion of  the  superficial  fascia,  may  also  be  observed.  In  later 
pregnancy  the  lower  extremities  may  be  somewhat  swollen, 
while  in  healthy  patients  the  general  appearance  of  the  body 
is  that  of  good  health  and  physiological  plethora. 

THE  DIAGNOSIS  OF  PREGNANCY  BY  PELVIC  EXAMINATION 

This  is  the  only  method  in  the  early  months  of  gestation 
which  the  physician  can  apply  to  the  solution  of  this  difficult 
subject.  So  important  an  examination  must  be  made  care- 
fully and  thoroughly,  and  with  as  little  disturbance  to  the 
patient  as  possible.  The  examination  which  has  preceded 
should  have  made  the  patient  more  at  her  ease  with  the  doc- 
tor and  have  prepared  the  way  for  the  internal  examination. 
Out  of  deference  to  the  patient's  feelings,  and  as  a  protection 
to  the  physician  in  dealing  with  unprincipled  women,  a  third 
person,  a  relative  of  the  patient  or  a  nurse,  should  be  present 
at  the  examination.  The  patient  should  be  in  proper  con- 
dition for  such  an  examination.  The  bladder  should  not  be 
distended  with  urine,  nor  the  abdomen  greatly  distended 
with  intestinal  gas.  The  patient  should  be  in  a  comfortable 
posture,  lying  upon  the  back  or  side,  the  urinary  bladder 
should  be  emptied,  and  if  possible  the  bowels  should  have 
been  moved  thoroughly  before  the  examination.  The  pa- 
tient should  not  be  chilled  and  unnecessary  exposure  should 
be  avoided. 

The  physician  should  render  his  hands  thoroughly  clean 
and  warm,  and  preferably  should  use  sterile  rubber  gloves. 
While  unquestionably  gloves  somewhat  deaden  the  sensi- 


DIAGNOSIS    OF    PREGNANCY   BY    PELVIC   EXAMINATION     73 

bility  of  the  finger-tips,  still  they  are  so  great  a  protection  to 
the  physician  against  syphilitic  and  other  infection,  and  a 
safeguard  to  the  patient  against  septic  infection,  that  they 
should  be  employed.  An  antiseptic  solution  should  be  used 
to  cleanse  the  external  parts  of  the  patient  and  also  to  disin- 
fect the  physician's  hands. 

If  the  vulva  be  inspected  during  pregnancy  it  will  be  found 
somewhat  discolored  and  often  enlarged,  the  veins  are  visible. 
On  vaginal  examination  it  may  be  noticed  that  the  vessels  in 
the  vagina  are  pulsating  strongly,  and  the  cervix  will  be 
found  invariably  softened  in  pregnancy.  The  degree  of 
softening  will  depend  upon  the  primiparity  or  multiparity 
of  the  patient  and  the  general  condition  of  her  tissues.  If 
the  patient  has  been  pregnant  a  number  of  times  the  cervix 
may  have  been  repeatedly  torn  and  its  edges  thicker  and  con- 
siderably firmer  than  normal.  Softening  in  such  a  cervix 
is  not  present  in  a  great  degree.  On  the  other  hand,  in  primi- 
parous  women  the  pregnant  cervix  is  often  as  soft  as  the  lips. 

In  examining  the  cervix  the  physician  must  also  note 
whether  it  is  in  any  degree  dilated.  In  first  pregnancies 
it  is  closed  by  a  plug  of  mucus  secreted  by  the  cervical  glands. 
If  the  patient  has  had  a  number  of  children  previously  the 
external  os  will  be  opened  and  may  readily  admit  one  or  even 
two  fingers. 

'  The  most  important  step  in  the  diagnosis  of  pregnancy 
is  the  study  of  the  contour  of  the  uterus  as  made  by  vaginal 
examination.  Having  observed  the  position  and  the  con- 
dition of  the  cervix,  the  examining  finger  should  then  be 
placed  upon  its  anterior  surface,  and  the  condition  of  the 
body  of  the  uterus  above  should  be  studied.  If  pregnancy  is 
present  the  body  of  the  uterus  will  be  enlarged  and  spherical. 
This  might  arise  from  other  causes  than  pregnancy,  but  if 
gestation  is  in  progress  the  lower  uterine  segment,  the  elastic 
tissue  between  the  body  and  the  cervix,  will  be  developed  suf- 
ficiently to  permit  its  recognition  by  the  finger.  If  the 
fingers  be  placed  upon  the  anterior  surface  of  the  cervix 
and  carried  upward  and  slightly  backward,  the  elasticity  of 
the  lower  segment  will  be  appreciated  and  the  lower  edge  of 
the  upper  expulsive  segment  will  be  found  as  a  ridge  or  rim 
above  the  fingers.  The  shape  of  the  uterus  will  resemble 


74  MANUAL   OF   OBSTETRICS 

that  of  a  round-bodied  jug  inverted,  the  neck  of  the  jug  cor- 
responding to  the  cervix,  the  body  of  the  jug  resembling  the 
body  of  the  uterus,  while  the  lower  segment  will  be  the 
groove  between  the  body  and  the  neck.  Especial  care  must 
be  taken  to  identify  the  lower  segment  and  the  globular  up- 
per segment  of  the  uterus.  Upon  this  recognition  depends 
the  diagnosis  of  early  pregnancy. 

Occasionally  patients  are  so  sensitive  to  examination  that 
a  satisfactory  vaginal  investigation  cannot  be  made  without 
anesthesia.  If  it  is  imperative  to  make  a  decision  concern- 
ing the  existence  of  pregnancy,  anesthesia  may  properly  be 
employed. 

In  some  multiparous  women  the  lower  segment  is  very 
difficult  to  recognize  in  early  pregnancy.  It  may  be  neces- 
sary to  defer  a  positive  diagnosis  in  such  cases  and  to  examine 
the  patient  several  times  at  intervals  of  two  or  three  weeks. 
Repeated  examination  will  rarely  fail  to  give  the  necessary 
information. 

While  diseased  conditions  of  the  uterus  may  cause  enlarge- 
ment of  the  body  of  the  womb,  and  while  the  globular  shape 
may  be  present  in  some  cases  of  fibroid  disease,  the  lower 
uterine  segment  does  not  develop  in  any  condition  except 
pregnancy.  Its  recognition  becomes  therefore  of  the  greatest 
importance. 

The  vaginal  examination  should  also  be  utilized  to  observe 
the  presence  or  absence  of  any  abnormal  condition  in  the 
pelvis.  In  ectopic  pregnancy  the  characteristic  changes 
in  the  uterus  may  be  present  to  some  degree,  but  the  position 
of  the  ovum  may  be  inferred  from  the  tenderness  elicited 
when  pressure  is  made  in  the  vicinity  of  the  Fallopian  tube, 
where  the  ovum  has  remained.  In  such  a  case,  while  the 
diagnosis  of  ectopic  pregnancy  may  not  be  positively  made, 
suspicion  should  be  aroused  and  the  patient  watched  ac- 
cordingly. 

THE  DIAGNOSIS  OF  LATER  PREGNANCY 

After  the  fourth  month  the  positive  diagnosis  of  pregnancy 
by  vaginal  examination  becomes  less  difficult.  By  abdominal 
palpation  the  fundus  can  usually  be  felt  above  the  pubis,  and 
at  the  sixth  month  some  idea  can  ordinarily  be  gained  con- 


THE   DIAGNOSIS   OF   LATER   PREGNANCY  75 

cerning  the  position  of  the  fetus.  At  the  seventh  month  the 
diagnosis  is  usually  possible  by  hearing  the  fetal  heart  sounds, 
outlining  its  body,  and  observing  the  movement  of  the  fetal 
limbs.  When  this  can  be  done  distinctly  a  positive  diagnosis 
of  pregnancy  can  be  absolutely  made.  Prior  to  this,  while 
a  probable  diagnosis  may  be  given,  it  cannot  be  positive. 

At  full  term  a  complete  diagnosis  of  pregnancy  must  em- 
brace not  only  its  existence,  but  the  position  and  presentation 
of  the  fetus,  the  period  of  gestation,  the  location  of  the  pla- 
centa, the  size  of  the  mother's  pelvis,  her  primiparity  or 


T 
Fig.  26. — Outlining  the  fetus  by  abdominal  palpation. 

multiparity,  and  the  comparative  size  of  mother  and  child. 
To  this  should  be  added  the  condition  of  the  mammary  glands. 
For  a  complete  examination  the  patient  must  lie  in  a  com- 
fortable position  on  her  back,  on  a  bed  or  table.  While  it  is 
customary  to  expose  the  abdomen  this  is  not  absolutely 
necessary,  and  one  thickness  of  soft  linen  is  not  an  obstacle 
to  an  accurate  diagnosis.  The  head  and  shoulders  of  the 
patient  should  be  raised  sufficiently  to  relax  the  abdominal 
walls.  The  physician  requires  for  such  an  examination  a 
stethoscope,  a  pelvimeter,  and  a  steel  tape-line.  Notes  should 
be  taken  of  various  data  which  the  examination  discloses. 


76 


MANUAL   OF   OBSTETRICS 


The  position  and  presentation  of  the  child  should  first  be 
made  out  by  palpation.  To  practice  this  the  physician's 
hands  must  be  thoroughly  cleaned  and  warm,  not  only  as  a 
matter  of  neatness  but  also  that  the  fingers  may  be  as  sensi- 
tive as  possible.  Standing  with  his  back  toward  the  patient's 
face  the  entire  hands  are  placed  on  each  side  of  the  abdomen 
and  sufficient  pressure  is  made  to  outline  the  body  of  the 
child.  Greater  resistance  on  the  left  or  right  side  will  indicate 
that  the  back  of  the  child  is  directed  toward  the  left  or  right 
side  of  the  mother.  By  making  gentle  pressure  upon  the 


Fig.  27. — Palpating  the  presenting  part. 

upper  portion  of  the  abdomen  the  thighs,  knees  and  legs  of 
the  fetus  can  often  be  detected.  By  carrying  the  pressure 
downward  to  the  brim  of  the  pelvis  it  is  usually  possible  to 
outline  the  head  and  to  observe  the  groove  or  depression  be- 
tween the  head  and  the  body,  which  indicate  the  neck.  If 
the  patient's  tissues  are  thin,  and  the  examiner  is  experienced, 
he  can  often  diagnosticate  the  presentation  of  the  head  which 
is  present.  Usually  the  vertex  is  lowermost  and  by  palpa- 
tion the  sides  of  the  head  are  felt. 

It  is  of  especial  importance  to  determine  the  presence  or 


THE   DIAGNOSIS    OF    LATER   PREGNANCY  77 

absence  of  engagement  of  the  presenting  part.  If  the  head 
be  freely  movable  at  the  pelvic  brim  there  is  no  engagement 
whatever.  If  the  head  be  slightly  movable  at  the  pelvic 
brim  it  may  have  entered  the  upper  portion  of  the  pelvis, 
but  not  have  completely  engaged.  Complete  engagement 
when  present  removes  part  of  the  head  from  the  pressure  of 
the  examining  hands.  The  physician  feels  but  that  portion 
of  the  head  which  is  above  or  just  beneath  the  pelvic  brim. 
The  head  is  immobile  or  very  slightly  movable  and  it  is  im- 
possible to  outline  the  rounded  shape  of  the  dome  of  the 
cranium.  Usually  the  position  of  the  head  can  be  determined 
and  the  fact  that  the  vertex  is  directed  toward  the  left  or  the 
right  side. 

No  examination  in  obstetrics  is  so  important  as  the  de- 
tection of  the  presence  or  absence  of  engagement  of  the 
presenting  part.  If  this  be  obscured  by  the  fulness  of  the 
patient's  urinary  bladder,  it  must  be  removed,  if  necessary 
by  the  use  of  the  catheter.  Palpation  at  the  pelvic  brim  is 
usually  more  successful  if  the  abdominal  muscles  be  relaxed, 
and  to  secure  this  the  patient  should  bend  the  thighs  upon 
the  body. 

Having  noted  the  position  of  the  back,  the  presenting 
part,  and  its  relative  position,  the  examiner  should  face  the 
patient  and  palpate  the  upper  portion  of  the  abdomen  and 
the  fundus  of  the  uterus.  Usually  the  breech  can  be  made 
out,  as  it  is  more  hard,  round  and  distinct  than  the  head. 
In  breech  presentation  the  head  will  be  found  at  the  fundus 
and  the  breech  at  the  pelvic  brim,  and  palpation  will  usually 
detect  the  difference  in  the  two  fetal  extremities. 

In  addition  to  position  and  presentation,  palpation  should 
give  valuable  knowledge  concerning  the  condition  of  the 
uterine  muscle  and  the  general  vigor  of  the  patient.  In  a 
well-nourished  primipara  palpation  finds  the  uterus  firm  and 
elastic  and  often  contracting  slightly  under  examination. 
In  a  relaxed  and  anemic  multipara  the  muscle  of  the  uterus 
is  less  firm  and  less  vigorous,  and  the  abdominal  wall  is  also 
relaxed  and  distended.  By  palpation  the  examiner  gains  a 
good  idea  concerning  the  strength  and  elasticity  of  the  muscle 
of  the  uterus  and  of  the  abdominal  muscles  as  well.  He  will 
also  observe  the  condition  of  the  intestine.  If  the  bowels 


78  MANUAL   OF   OBSTETRICS 

are  relaxed  and  distended  with  gas  this  will  obscure  palpation 
and  furnish  another  indication  of  the  lack  of  vigor  in  the 
patient.  If  the  bowels  are  contracted  and  gas  in  large 
quantity  is  not  present,  it  will  indicate  a  more  normal  and 
vigorous  state. 

Palpation  should  also  give  evidence  of  multiple  pregnancy. 
If  two  heads,  for  example,  can  be  palpated  it  is  probable  that 
twin  pregnancy  is  present.  The  presence  of  a  monstrosity 
is  possible,  but  not  usual. 

RECOGNITION    OF    UNUSUAL    POSITIONS    AND    PRESENTA- 
TIONS 

Transverse  position  and  shoulder  presentation  of  the 
fetus  may  be  recognized  by  palpation.  The  head  will  be 
found  at  one  side,  usually  in  the  left  iliac  fossa,  the  breech 
and  limbs  at  the  right,  the  back  and  shoulder  at  the  pelvic 
brim.  Should  the  back  be  posterior  the  arms  and  hands  will 
be  in  front. 

Oblique  positions  of  the  fetus  through  some  abnormality 
which  prevents  the  descent  of  the  child,  may  also  be  recog- 
nized. Failure  of  flexion,  producing  face  or  brow  presenta- 
tion and  lateral  partial  rotation  of  the  head,  which  results  in 
parietal  bone  presentation,  may  be  detected  by  palpation  in 
patients  with  thin  tissues. 

POSITION 

The  simplest  and  most  rational  idea  of  position  is  that 
which  makes  two — the  first  position,  in  which  the  back  of  the 
child  and  the  presenting  part  are  directed  toward  the  left  side 
of  the  mother's  abdomen  and  pelvis ;  and  the  second  position, 
in  which  the  back  and  presenting  part  are  directed  toward  the 
right.  Posterior  positions  of  the  back  and  presenting  part 
are  most  rationally  considered  as  abnormal  rotations,  and  this 
conception  aids  in  studying  labor. 

MULTIPLE  PREGNANCY 

In  palpating  more  than  one  fetus,  a  positive  diagnosis 
of  multiple  pregnancy  cannot  be  made  by  palpation  unless 
the  examiner  can  clearly  outline  two  fetal  heads  and  one 
breech,  or  one  head  and  two  breeches. 


AUSCULTATION  79 

FETAL  MOVEMENTS 

During  palpation  the  disturbance  caused  usually  produces 
fetal  movements.  These  are  of  two  kinds,  the  folding  and 
unfolding  of  the  fetal  body,  comparatively  slow  gradual 
movements,  and  the  sudden  rapid  motion  of  the  knees  and 
elbows,  which  indicate  movements  of  the  fetal  limbs.  The 
larger  movements  are  felt  upon  the  left  or  right  sides  of  the 
mother's  abdomen,  the  quick  and  sharper  motions  on  the 
right  side,  above  and  below,  or  on  the  left  side  above  and  be- 
low. 

AUSCULTATION 

While  the  recognition  of  movements  indicates  that  the 
fetus  lives,  hearing  the  fetal  heart  beat  proves  its  existence. 
This  is  heard  more  commonly  on  the  left  side  of  the  mother's 
abdomen,  midway  between  the  umbilicus  and  the  anterior 
superior  spine  of  the  ilium.  Should  the  position  be  second 
the  fetal  heart  sounds  will  be  heard  at  the  corresponding  posi- 
tion on  the  right  side.  As  the  child  enters  the  pelvis  the 
heart  sound  is  lower.  If  the  back  of  the  child  is  posterior 
the  heart  sound  is  less  distinct.  When  the  breech  presents 
the  heart  sound  is  upon  the  left  or  right  side  at  the  level,  or 
above  a  line  drawn  transversely  through  the  umbilicus.  In 
shoulder  presentation  transverse  position,  the  heart  sound  is 
in  the  centre  above  the  pubis.  In  abnormal  positions  and 
rotations  it  may  be  heard  low  at  the  sides  of  the  abdomen. 

While  some  prefer  to  use  a  stethoscope,  the  heart  sounds 
can  be  heard  more  accurately  and  quickly  by  placing  the 
ear  against  the  abdominal' wall,  covered  with  one  layer  of 
thin  linen.  Some  prefer  the  phonendoscope  to  detect  heart 
sounds. 

The  Placental  Sound. — The  blood  passing  through  the 
large  uterine  sinuses  where  the  placenta  is  attached  gives  rise 
to  a  beating,  hissing  sound  called  the  placental  bruit.  It  is 
nearly  synchronous  with  the  mother's  pulse,  slower  and  some- 
times louder  than  the  fetal  heart,  and  covers  a  larger  area  than 
the  fetal  heart.  It  is  best  recognized  by  listening  while  the 
observer  takes  the  radial  pulse  of  the  mother  and  identifies 
the  two  as  maternal  and  not  fetal  sounds. 

When  the  placenta  and  the  back  of  the  child  are  upon 


80 


MANUAL   OF    OBSTETRICS 


the  same  side  of  the  uterus  the  placenta  may  obscure  the 
fetal  heart  sounds.  The  diagnosis  is  then  made  by  failure 
to  find  a  fetal  heart  sound  elsewhere,  by  locating  the  fetus 
by  palpation,  and  by  pressing  the  ear  gently  into  the  abdom- 
inal wall,  when  the  fetal  heart  sounds  will  become  evident 
as  well  as  the  placental  sound. 

Abnormal    Sounds. — The    hissing   rapid   sound,    a   little 
slower  than  the  fetal  heart,  and  more  rapid  than  the  placental 


Fig.  28. — The  fetal  heart  sounds. 

sound,  indicates  a  murmur  in  the  umbilical  cord  coiled  about 
the  child.  Two  or  more  distinct  heart  sounds  are  signs  of 
multiple  pregnancy.  Gas  hi  the  intestine  of  the  mother  and 
a  very  strongly  beating  maternal  aorta  may  confuse  the 
examiner. 

Prognosis  by  Auscultation. — No  definite  prognosis  concern- 
ing sex  or  the  vigor  of  the  fetus  can  be  made  by  auscultation. 


THE   MEASUREMENT   OF   THE    PELVIS  81 

If  the  heart  sound  is  more  rapid  than  140  the  fetus  is  prob- 
ably female;  if  slower  than  140  probably  male.  Experience 
will  enable  the  physician  to  recognize  the  heart  sound  as  of 
average  or  greater  strength.  During  labor,  birth  pressure  or 
maternal  hemorrhage  may  cause  the  fetal  heart  to  beat  at 
first  more  rapidly,  then  slowly,  weakly,  and  faintly,  indicat- 
ing danger  to  fetal  life. 

Fetal  movements  are  sometimes  appreciated  by  the  ear, 
as  the  limbs  strike  against  the  walls  of  the  uterus.  In 
threatened  asphyxia  these  movements  may  become  rapid  and 
violent  for  a  short  time. 

THE  MEASUREMENT  OF  THE  PELVIS 

In  the  living  patient  the  pelvis  is  measured  by  external 
and  internal  pelvimetry. 

External  pelvimetry  is  done  by  calipers  called  a  pelvim- 
eter.  For  this  the  patient  lies  upon  her  back,  with  the 
abdomen,  pelvis  and  upper  thighs  covered  by  one  thickness 
only  of  thin  linen.  The  physician  then  measures  between 
the  anterior  superior  spines,  normally  24  to  26}/2  cm.;  be- 
tween the  outermost  crests,  normally  28  cm.;  between  the 
trochanters  and  the  femora,  normally  32  cm.  These  are 
measures  of  width  at  the  pelvic  brim. 

The  patient  is  asked  to  turn  slightly  upon  her  right 
side,  raising  the  left  hip.  One  limb  of  the  pelvimeter 
is  then  placed  on  the  posterior  superior  spine  of  the  left 
side,  the  other  upon  the  anterior  superior  spine  of  the 
right  side.  This  measurement,  the  left  oblique  diagonal,  is 
normally  22  cm.  The  patient  is  then  asked  to  turn  upon 
the  left  side,  when  the  pelvimeter  is  placed  upon  the  right 
posterior  superior  spine  and  the  left  anterior,  measuring 
the  right  oblique  diameter,  223/£  to  23  cm.  The  patient 
should  then  lie  upon  the  left  side  with  the  thighs  very  slightly 
flexed  or  almost  extended,  the  body  raised  squarely  upon  the 
left  shoulder,  side,  hip  and  thigh.  Passing  the  fingers  down 
the  spinous  processes  of  the  vertebrae  the  physician  comes 
upon  the  depression  beneath  the  spine  of  the  last  lumbar 
vertebra.  This  may  also  be  located  by  sight,  by  exposing 
the  posterior  surface  of  the  sacral  and  lumbar  regions,  when 
6 


82 


MANUAL   OF   OBSTETRICS 


two  depressions  or  dimples  will  be  noticed,  one  on  each  side 
of  the  line  of  the  spine.  If  an  imaginary  line  be  drawn  be- 
tween them  transversely,  the  spine  of  the  last  lumbar  verte- 
bra will  be  found  just  above  the  centre  of  this  line.  The 
pelvimeter  should  be  placed  in  the  depression  beneath  the 
spine  of  the  last  lumbar  vertebra  and  its  other  limb  on  the 
middle  of  the  pubes  in  front.  This  gives  the  external  antero- 
posterior  diameter  20J/2  cm.  The  circumference  of  the  pelvis 
is  obtained  by  placing  the  patient  upon  her  back  and  meas- 


Fig.  29. — Obtaining  the  transverse  diameter  of  the  pelvis  by  external 

pelvimetry. 


uring  with  a  tape-line  around  the  pelvis  just  below  the  crests 
of  the  ilium — 85  to  90  cm. 

At  the  pelvic  outlet  the  distance  between  the  tuberosities 
of  the  ischia  may  be  measured  with  the  pelvimeter  or  a  tape- 
line,  by  turning  the  patient  upon  her  side,  or  by  having  an 
assistant  raise  the  thighs  perpendicularly  and  support  the 
knees.  This  distance  is  ordinarily  11  cm. 

Internal  Pelvimetry. — This  may  be  done  by  the  hand  or  by 
instruments;  usually  the  hand  suffices.  The  most  impor- 


THE   MEASUREMENT   OF   THE    PELVIS 


83 


tant  measurement  is  that  from  the  lower  border  of  the  sym- 
physis  to  the  promontory  of  the  sacrum.  To  accomplish 
this  the  patient  must  be  upon  the  back  with  her  hips  project- 
ing slightly  over  the  bed  or  table.  The  legs  and  thighs  must 
be  flexed  and  supported.  The  hands  of  the  examiner  should 
be  made  sterile,  or  covered  with  sterile  gloves.  The  hands, 
gloved  or  ungloved,  should  be  thoroughly  warmed,  and  the 


Fig.  30. — The  external  conjugate,  antero-posterior  diameter,  by  exter- 
nal pelvimetry. 


hand  which  is  to  be  inserted  should  be  anointed  with  a  lubri- 
cant. In  primiparae,  but  the  first  and  second  fingers  can  be 
inserted,  and  these  should  be  passed  directly  backward  in 
the  vagina  until  the  fingers  reach  the  posterior  wall  of  the 
pelvis.  The  elbows  should  then  be  dropped  as  low  as  pos- 
sible, and  the  fingers  passed  upward  with  gentle  but  con- 
tinuous pressure  until  the  promontory  of  the  sacrum  can  be 
felt.  The  upper  border  of  the  internal  hand  should  then  be 


84 


MANUAL   OF   OBSTETRICS 


brought  against  the  lower  edge  of  the  symphysis,  and  its 
position  marked  by  the  unemployed  hand.  When  the  hand 
is  withdrawn  the  distance  from  the  tip  of  the  longest  finger 
to  the  point  marked  on  the  edge  of  the  hand  should  be  meas- 
ured. The  fingers  should  again  be  inserted  and  the  height 
of  the  symphysis  measured  as  accurately  as  possible.  From 


Fig.  31. — Measuring  the  transverse  diameter  of  the  pelvic  outlet 
(Liepmann). 

the  longer  measurement  should  be  subtracted  the  height  of 
the  symphysis,  which  will  give  the  internal  antero-posterior 
diameter  or  conjugata  vera.  The  measurement  from  the 
promontory  of  the  sacrum  to  the  lower  border  of  the  sym- 
physis is  normally  13  cm. ;  the  height  of  the  symphysis  2  cm., 
making  the  conjugata  vera  11  cm. 


THE    MEASUREMENT   OF   THE    PELVIS 


85 


To  measure  the  antero-posterior  diameter  of  the  pelvic 
outlet  the  distance  must  be  taken  between  the  lower  margin 
of  the  symphysis  pubis  to  the  tip  of  the  coccyx.  This  may 
be  measured  with  the  hand  or  with  an  instrument,  being  9.5 
cm.  and  increased  2  cm.  by  the  backward  motion  of  the 
coccyx. 

The  advantage  of  using  the  hand  for  internal  pelvimetry 
lies  in  the  fact  that  the  sensitive  fingers  appreciate  irregu- 
larities in  the  contour  of  the  pelvis.  The  pelvis  should  be 
palpated  internally  in  all  cases  where  abnormality  is  sus- 


Fig.  32. — The  internal  conjugate,  anteroposterior  diameter,  by  vaginal 
examination  (after  Bumm). 

pected.  Instruments  designed  for  internal  pelvimetry  are 
practically  a  long  finger  with  a  sliding  scale. 

Measuring  the  Comparative  Size  of  Pelvis  and  Child.— 
This  is  the  most  important  clinical  measurement  which 
can  be  made  and  should  never  be  omitted.  Upon  this 
may  depend  an  important  decision  regarding  treatment. 

If  on  palpation  the  head  is  found  presenting  and  it  is  ob- 
served that  the  greater  portion  of  the  head  is  under  the  pelvic 
brim,  and  if  the  vaginal  examination  confirms  the  presence 
of  engagement,  the  head  is  certainly  proportionate  in  size 
to  the  pelvis.  Normal  uterine  and  muscular  action  will 


86 


MANUAL   OF   OBSTETRICS 


bring  the  presenting  part  where  the  physician,  if  necessary, 
can  deliver  the  child  through  the  vagina. 


Fig.  33. — The  fetal  head,  anteroposterior  and  biparietal  diameters:  PP, 
biparietal  diameter  (Faraboeuf  and  Varnier). 


Fig.  34. — Measurements  of  fetal  head  in  centimeters:  OF,  occipito- 
frontal  diameter;  OB,  suboccipito-bregmatic;  BT,  trachelo-bregmatic. 
Maximum  diameter  indicated  by  long  dotted  lines  (Faraboeuf  and 
Varnier). 

If  on  palpation  the  head  is  presenting  but  is  not  yet  en- 
gaged, it  is  important  to  ascertain  as  nearly  as  possible 


GENERAL    DATA    OBTAINED    BY    EXAMINATION  87 

whether  it  can  enter  the  pelvis.  If  the  head  is  freely  mov- 
able above  the  pelvic  brim,  it  is  sometimes  called  the  floating 
head.  For  this  the  patient's  urinary  bladder  must  be  com- 
pletely emptied.  She  must  lie  upon  her  back  with  the  legs 
and  thighs  flexed  and  supported,  and  her  hips  projecting 
slightly  over  the  edge  of  a  bed  or  table.  While  an  assistant 
places  his  hand  broadly  across  the  fundus  of  the  uterus  the 
examiner  introduces  the  longest  fingers,  or  the  whole  of  one 
hand  within  the  vagina,  carrying  the  finger-tips  up  to  the 
pelvic  brim.  The  other  hand  should  then  grasp  the  head 
with  thumb  and  fingers,  and  while  the  assistant  presses  gently 
downward  the  examiner  should  carry  the  head  gently  but 
firmly  downward  and  backward  at  the  pelvic  brim.  The 
fingers  of  the  internal  hand  should  note  whether  the  head 
enters  the  pelvic  brim,  or  whether  it  cannot  do  so. 

A  frequent  source  of  error  in  this  examination  lies  in  the 
fact  that  the  head  instead  of  entering,  may  dip  one  parietal 
bone  into  the  pelvic  cavity  without  actually  engaging  in  the 
pelvic  brim.  This  constitutes  a  parietal  bone  presentation, 
which  is  an  impossible  position  of  the  head  for  labor  and 
which  indicates  a  serious  abnormality. 

In  cases  where  pregnancy  is  prolonged  or  where  there 
is  abnormality  in  the  mother's  size,  or  disproportion,  this 
procedure  may  be  used  to  determine  the  induction  of  labor. 
It  then  becomes  of  especial  importance,  and  if  necessary  an- 
esthesia may  be  employed  for  a  successful  examination. 

THE  POSITION  OF  THE  PLACENTA 

Very  rarely  in  thin  patients  with  relaxed  tissues  the  pla- 
centa can  be  felt  by  palpation.  It  sometimes  alters  the  con- 
tour of  the  uterus,  especially  if  it  lodges  in  one  cornu,  so  that 
its  presence  may  be  inferred  by  a  projection  in  the  wall  of  the 
uterus.  Ordinarily  the  recognition  of  the  placental  bruit, 
already  described,  indicates  the  location  of  the  placenta.  It 
is  especially  important  to  recognize  this  bruit  low  at  the 
pelvic  brim  in  cases  of  placenta  prsevia. 

GENERAL  DATA  OBTAINED  BY  EXAMINATION 

By  the  examination  of  the  pregnant  patient  just  described, 
the  examiner  should  form  a  fairly  correct  idea  concerning  the 


88  MANUAL   OF   OBSTETRICS 

development  and  vigor  of  the  patient's  abdominal  and  uterine 
muscle.  He  can  also  ascertain  the  development  of  the  lower 
portion  of  the  genital  tract,  and  can  usually  recognize  the 
primiparity  or  multiparity  of  the  patient.  The  imminence 
of  labor  is  evident  where  the  examiner  finds  the  presenting 
part  low  in  the  pelvis  and  the  cervix  soft  and  partially  or 
completely  dilated.  If  an  unusually  long,  hard  and  resisting 
cervix,  undilated,  be  present,  with  lack  of  development  in 
the  uterine  and  abdominal  muscle,  it  will  be  evident  that 
long  and  difficult  labor  may  be  anticipated. 

THE  DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY 

An  essential  in  the  diagnosis  of  pregnancy  is  the  recogni- 
tion of  the  living  fetus  by  feeling  its  movements  and  hearing 
its  heart  sounds.  As  the  fetus  may  be  dead,  it  is  necessary 
to  differentiate  pregnancy  from  other  tumors  and  abnormal 
conditions  whenever  possible. 

In  ascites,  with  the  patient  lying  upon  her  back,  there  is 
tympany  on  percussion  over  the  centre  of  the  abdomen, 
and  dulness  at  the  borders  of  the  flanks.  In  pregnancy  there 
is  dulness  over  the  centre  of  the  abdomen  and  tympany 
of  the  border  and  flanks.  With  large  fibroid  tumors  of  the 
uterus  the  outline  of  the  tumor  is  usually  nodular  and  ir- 
regular. The  uterus  in  pregnancy  is  smooth  and  regular  in 
contour.  Intermittent  uterine  contractions  may  alter  its 
shape,  but  such  contractions  do  not  persist.  A  large  sym- 
metrical uterine  fibroid  which  had  undergone  cystic  degen- 
eration in  a  patient  might  simulate  very  closely  the  shape, 
size,  and  consistence  of  the  pregnant  uterus.  If  the  fetus 
were  living  its  recognition  would  make  clear  the  diagnosis, 
so  a  solid  and  cystic  tumor  of  the  ovary  might  resemble  the 
pregnant  uterus  if  no  movements  or  heart  sounds  could  be 
made  out. 

A  dislocated  spleen  or  kidney  might  descend  as  low  as  the 
pelvic  brim,  but  such  has  not  the  consistence  of  the  uterus  and 
its  contents,  nor  could  the  fetus  be  recognized.  A  large 
ovarian  cyst  might  closely  resemble  the  uterus  distended 
from  amniotic  dropsy,  and  the  abdomen  has  been  opened  and 
the  uterus  in  this  condition  opened,  under  the  belief  that  the 


DIFFERENTIAL    DIAGNOSIS  89 

operator  was  about  to  remove  an  ovarian  tumor.  The  ir- 
regular outline  caused  by  multiple  pregnancy  is  sometimes 
confusing  especially  if  the  amniotic  liquid  is  in  excess.  The 
distended  abdomen  in  pseudo-cyesis  may  resemble  closely 
the  contour  of  pregnancy,  but  on  palpation  no  fetus  can  be 
made  out,  nor  can  heart  sounds  be  heard  on  auscultation. 
The  use  of  an  anesthetic  causes  the  phantom  tumor  to  dis- 
appear. 

Tubercular  peritonitis  and  encysted  fluid  may  closely 
resemble  pregnancy,  but  here  again  no  fetus  can  be  recog- 
nized. 

In  some  cases  the  diagnosis  of  pregnancy  or  its  absence  is 
so  important  that  anesthesia  should  be  used,  if  necessary, 
to  complete  the  examination.  No  reliance  can  be  placed  in 
differential  diagnosis  upon  the  statements  of  a  patient.  Vag- 
inal examination  is  of  value,  but  softening  of  the  cervix  is 
sometimes  present  in  conditions  other  than  pregnancy.  The 
recognition  of  the  lower  uterine  segment  in  early  pregnancy 
is  the  most  important  function  of  vaginal  examination  in 
these  cases. 

At  ten  weeks  the  uterus  is  as  large  as  a  good  sized  closed 
fist;  at  three  months  as  large  as  a  fist  with  a  hand  placed 
over  it;  at  four  months  the  fundus  can  be  made  out  at  the 
pubes;  at  five  months  the  fundus  is  midway  between  the 
pubes  and  umbilicus;  at  six  months  the  fundus  is  at  the 
umbilicus;  at  seven  months  two  fingers'  breadth  above  it; 
at  eight  months  a  hand's  breadth  above;  at  nine  months  dis- 
tending the  tissues  at  the  tip  of  the  sternum;  at  ten  months, 
in  the  primipara,  it  has  descended  into  the  pelvic  brim;  in 
the  multipara  the  relaxed  abdominal  muscles  permit  the 
fundus  to  fall  forward  while  the  presenting  part  remains  mo- 
bile above  the  pelvic  brim. 

THE  DIAGNOSIS  OF  PREGNANCY  BY  OTHER  MEANS  THAN 
PHYSICAL  EXAMINATION 

Lately  the  effort  has  been  made  to  diagnosticate  pregnancy 
by  studying  the  blood  and  the  excretions  of  the  mother.  In 
the  former  Abderhalden's  serum  test  for  pregnancy  has 
aroused  much  interest.  If  the  embryo  be  considered  a  for- 
eign body  growing  at  the  expense  of  the  mother,  and  threaten- 


90  MANUAL    OF   OBSTETRICS 

ing  her  existence  by  the  development  of  fetal  tissue  in  the 
syncytium,  the  maternal  organism  will,  if  possible,  protect 
itself  against  the  invader.  This  it  will  do  by  producing 
ferments  which  can  be  recognized  in  the  blood  plasma. 

Abderhalden  discovered  that  during  pregnancy  albumi- 
noid matter  derived  from  the  placenta  is  digested  by  the 
mother's  blood  ferments.  The  villi  of  the  chorion  are  thus 
dealt  with  before  the  placenta  is  formed.  These  ferments  are 
recognized  as  early  as  the  first  month  and  disappear  usually 
within  ten  days  after  labor,  at  term,  or  abortion. 

To  recognize  pregnancy,  the  placental  tissue  is  subjected, 
in  small  quantities,  to  the  digestive  action  of  fresh  blood 
serum  from  the  patient  in  whom  diagnosis  is  desired.  This 
is  done  by  dialysis  in  a  suitable  tube.  The  results  can  be 
recognized  by  color  tests.  The  polariscope  can  also  be  em- 
ployed. 

It  is  evident  that  this  method  will  be  useful  in  cases  where 
pregnancy  is  suspected,  but  evidence  that  the  ovum  is  within 
the  uterus  is  not  forthcoming.  It  has  been  successful  in 
many  cases,  but  it  has  also  been  found  that  a  similar  result 
is  obtained  in  non-pregnant  patients  the  subject  of  diseases 
which  profoundly  alter  the  patient's  metabolism.  It  should 
be  employed  hi  all  doubtful  cases,  but  should  not  be  taken 
hi  the  present  stage  of  our  knowledge  as  absolutely  conclusive. 

In  early  pregnancy  there  is  the  usual  moderate  anemia  and 
leukocytosis,  later  giving  place  to  plethora  with  a  high  per- 
centage of  fibrin  and  red  cells. 

The  examination  of  the  excretions  of  a  patient  to  determine 
the  existence  of  pregnancy  is  interesting,  but  often  not  con- 
clusive. Blood  serum  from  a  pregnant  patient  injected  into 
animals  may  produce  disturbance  or  it  may  not. 

If  the  pregnant  patient  be  tpxemic  it  may  produce  con- 
vulsions and  death. 

An  effort  has  been  made  to  diagnosticate  pregnancy  by 
recognizing  abnormal  bodies  in  the  urine.  Acetone,  indican 
and  other  substances  have  been  thought  to  indicate  preg- 
nancy. There  are,  however,  so  many  conditions  of  disturbed 
metabolism  in  which  these  substances  are  present  that  their 
existence  cannot  be  considered  as  positive  proof  of  gestation. 

The  urine  in  pregnancy,  however,  always  indicates  hi- 


DIFFERENTIAL    DIAGNOSIS  91 

creased  metabolism  and  excretion  burdened  to  the  limit. 
The  percentage  of  urea  is  usually  lessened,  the  rest  nitrogen, 
creatin  and  creatinin  and  ammonia,  are  increased;  hyaline 
casts  are  not  uncommon,  and  a  small  quantity  of  serum  al- 
bumin is  often  present.  As  gestation  comes  to  its  close  milk- 
sugar  is  often  detected  and  lactosuria  may  become  pro- 
nounced. The  specific  gravity  and  the  quantity  of  the  urine 
vary  greatly  in  different  patients. 

THE  DIAGNOSIS  OF  PREGNANCY  WITH  THE  DEATH  OF  THE 
EMBRYO  OR  FETUS 

When  the  embryo  dies  and  is  retained,  if  it  be  within  the 
uterus  a  slight  discharge  of  dark-reddish  fluid  usually  per- 
sists while  the  uterus  remains  slightly  larger  than  normal;  the 
changes  in  the  breasts  disappear,  and  disturbances  in  appe- 
tite and  digestion  cease,  and  the  patient  returns  gradually 
to  her  normal  condition.  The  blighted  ovum  is  usually  ex- 
pelled after  a  varying  time,  and  occasionally  is  completely 
absorbed.  Should  the  syncytium  grow  excessively,  syncy- 
tioma  malignum  may  develop. 

The  death  of  the  fetus  in  utero  may  be  appreciated  by -the 
cessation  of  fetal  movements,  failure  to  hear  fetal  heart 
sounds,  and  the  gradual  absorption  of  the  amniotic  liquid, 
which  causes  the  abdominal  tumor  to  decrease  in  size.  The 
patient  may  feel  less  disturbance  in  digestion  for  a  few  days, 
but  if  the  fetus  be  retained  long  hi  the  uterus  a  condition  of 
toxemia  is  produced  from  absorption  from  the  dead  child. 

If  the  ectopic  fetus  dies,  its  death  is  often  followed  by 
colicky  abdominal  pain,  which  gradually  ceases.  The 
mother's  health  may  not  be  much  disturbed,  and  if  the  fetus 
and  its  appendages  do  not  become  infected  by  bacteria 
from  the  adjacent  bowel  the  fetus  may  undergo  changes  and 
remain  indefinitely  in  the  mother's  abdomen.  The  amni- 
otic liquid  will  be  absorbed  and  the  placenta  may  gradually 
become  a  thin  fibrous  mass.  Such  a  fetus  may  undergo  cal- 
careous changes,  becoming  a  lithopedion.  When  the  dead 
fetus  is  retained  in  utero  with  unruptured  membranes  it 
becomes  softened  from  the  amniotic  liquid,  and  the  process 
known  as  maceration  ensues. 

Mothers  are  often  alarmed  by  the  apparent  cessation  of 


92  MANUAL   OF   OBSTETRICS 

fetal  movements,  when  such  is  not  really  the  case.  A  care- 
ful examination  will  often  detect  natural  movement,  and 
if  the  heart  sounds  are  of  average  strength  and  vigor  there 
is  no  occasion  for  anxiety. 

THE  DIAGNOSIS  OF  PREGNANCY  BY  THE  X-RAY 

When  pregnancy  is  advanced  so  far  that  the  fetal  skeleton 
is  well  formed,  the  X-ray  will  give  an  outline  of  the  fetus 
which  may  be  available  for  diagnosis.  The  picture  of  the 
fetus  will  be  successful  in  proportion  as  the  head  has  not 
entered  the  pelvic  cavity.  If  it  be  low  down,  the  pelvic 
walls  will  obscure  the  outline  of  the  fetal  cranium.  The 
position  of  the  child  in  the  pelvis,  the  presence  of  pelvic 
deformity,  multiple  pregnancy,  and  sometimes  fetal  deform- 
ity, may  be  outlined  in  this  way.  Accurate  pelvimetry  can 
be  accomplished  by  using  the  normal  pelvis  as  a  standard  of 
comparison,  and  utilizing  its  standard  diameters  for  the 
measurement  of  the  abnormal. 


CHAPTER  VIII 
THE  PHYSIOLOGY  OF  PREGNANCY 

The  most  significant  changes,  aside  from  those  occurring 
in  the  genital  tract  found  in  the  pregnant  woman,  are  those 
in  the  blood  and  in  the  organs  of  excretion  and  assimilation. 

The  Blood. — The  weight  of  the  body  increases  during  preg- 
nancy and  at  first  the  weight  of  the  blood  does  not  maintain 
its  usual  proportion.  As  pregnancy  advances  the  red  blood 
cells  increase  in  number,  while  the  hemoglobin  at  first  is 
slightly  diminished  and  afterwards  increased.  There  is  a 
notable  gain  in  the  quantity  of  fibrin,  which  coincides  with 
a  moderate  leukocytosis.  This  is  found  more  pronounced 
in  multiparse  than  in  primiparse,  and  where  the  fetus  is  a  fe- 
male rather  than  when  a  male  child  is  born.  If  the  patient 
be  not  well  nourished  during  pregnancy  the  alkalinity  of  the 
blood  increases. 

The  Heart  and  Pulse. — The  shape  of  the  heart  changes 
somewhat  as  pregnancy  advances,  through  the  upward  mo- 
tion of  the  diaphragm.  The  walls  of  the  ventricles  are  in- 
creased hi  thickness,  and  the  muscle  of  the  heart  undergoes 
growth,  which  is  comparable  to  that  of  the  uterine  muscle. 
Murmurs  are  heard  not  infrequently  over  the  apex  of  the 
heart  but  cannot  be  connected  with  valvular  disease.  The 
action  of  the  heart  is  increased  in  frequency,  the  tension  of 
the  pulse  somewhat  higher  than  in  the  non-pregnant,  and 
the  heart  action  and  pulse  are  remarkable  for  their  quick 
and  frequent  change  in  rapidity  and  tension.  Any  disturb- 
ance of  the  nervous  system  disturbs  the  heart  and  pulse  ten- 
sion at  once. 

The  Respiratory  Organs. — As  the  growing  uterus  and  its 
contents  press  the  diaphragm  upward  the  capacity  of  the 
lungs  is  decreased.  In  pregnancy  the  patient  breathes  with 
the  thorax  only,  the  thorax  expanding  from  side  to  side  as 

93 


94  MANUAL   OF   OBSTETRICS 

pregnancy  advances.  As  the  position  of  the  heart  is  readily 
altered  and  pressure  is  brought  to  bear  upon  the  diaphragm 
by  motion,  the  respiration  and  heart  action  are  alike  very 
easily  disturbed  during  pregnancy.  The  fact  that  the  capac- 
ity of  the  lungs  is  decreased  is  illustrated  by  the  frequent 
fainting  which  occurs  among  pregnant  women  when  they 
are  in  a  close  or  ill-ventilated  room,  and  their  almost  constant 
craving  for  fresh  air. 

The  Digestive  Organs. — In  early  pregnancy  the  secretion 
of  the  salivary  glands  is  very  markedly  increased,  and  in 
patients  not  in  good  condition  may  become  so  excessive  as 
to  be  greatly  annoying.  In  half  of  all  pregnant  patients 
there  is  some  disturbance  of  the  stomach  in  the  early  morning, 
usually  terminating  in  brief  vomiting.  In  one-third  of  preg- 
nant patients,  loss  of  appetite  and  dyspepsia  develops  as 
pregnancy  advances.  The  material  vomited  is  usually 
acid  and  often  acrid  mucus. 

Constipation. — It  is  safe  to  say  that  no  patient  goes  through 
pregnancy  without  constipation.  While  the  bowels  may 
move  daily,  the  quantity  of  fecal  matter  discharged  is  in- 
sufficient, and  feces  accumulate  and  in  extreme  cases  become 
dried  and  adherent  to  the  wall  of  the  intestine.  Distention 
of  gas  occurs,  in  many  patients  complicating  constipation. 
Where  fecal  matter  decomposes  and  gas  accumulates  in 
great  quantities,  an  examination  of  the  pregnant  abdomen 
may  be  greatly  hindered  by  this  condition. 

Disorders  of  the  appetite  are  very  common  in  pregnancy 
and  usually  indicate  some  disturbance  in  the  digestive  organs. 
Patients  frequently  crave  acids  and  acid  fruits,  while  many 
cannot  take  articles  of  food  which  were  formerly  acceptable. 
The  longing  for  acids  is  the  natural  result  of  a  sluggish  con- 
dition of  the  digestive  organs  when  patients  have  disturbed 
metabolism.  Some  patients  dislike  meat  and  crave  the 
lighter  and  more  digestible  articles  of  food  and  have  a  desire 
for  at  least  the  average  or  more  than  the  average  quantity 
of  fluid.  The  appetite  and  craving  of  pregnant  women  for 
substances  normally  indicated  during  pregnancy  must  be 
considered  an  evidence  of  health.  Abnormal  cravings  for 
indigestible  and  unusual  articles  of  food  should  be  taken  as 
evidences  of  disease. 


THE    PHYSIOLOGY    OF   PREGNANCY  95 

Secretion  of  Urine.— The  quantity  of  urine  excreted  in  24 
hours  varies  greatly  in  pregnant  women.  In  ten  patients 
studied  by  the  writer  the  quantity  varied  from  40  to  80  fluid 
ounces.  The  average  among  these  patients  was  59.92  ounces, 
and  the  patients  were  under  hospital  observation,  taking  no 
medicine,  and  upon  a  mixed  diet  of  digestible  food.  All 
were  doing  light  work  about  the  wards.  The  conditions  were 
such  that  they  represented  a  fair  average.  The  quantity 
of  urine  should  increase  but  slightly  above  the  average,  and 
should  the  converse  be  true  the  condition  is  not  that  of  nor- 
mal health.  In  many  patients  the  coloring  matter  of  the 
urine  is  greatly  increased,  and  peptone  and  milk  sugar  are 
occasionally  found.  In  many  albumin  is  present  during 
the  early  months  of  pregnancy,  and  hi  some  a  slight  trace 
exists  throughout  the  entire  time.  A  considerable  quan- 
tity of  serum  albumin  is  not  normally  present  in  the 
urine  during  pregnancy.  Hyaline  casts  are  occasionally 
present,  with  leukocytes  and  bladder  epithelium,  but  large 
numbers  of  epithelial  casts  are  never  present  in  health. 
Small  quantities  of  sugar  may  be  present  in  the  urine  with 
increase  of  sulphates. 

The  nitrogen  partition  of  urine  in  normal  pregnancy 
shows  a  diminution  of  the  quantity  of  urea,  and  an  increase 
in  the  creatin  and  creatinin  and  rest  nitrogen.  The  am- 
monia coefficient  is  often  slightly  increased.  As  pregnancy 
advances  and  the  fetus  becomes  fully  developed,  especially 
as  delivery  approaches,  the  quantity  of  urea  increases  and 
the  other  nitrogenous  constituents  grow  less  in  quantity. 
There  is  evidence  that  glycogen  is  stored  up  in  the  liver  dur- 
ing pregnancy  and  that  sugar  is  discharged  in  the  urine  in 
much  less  quantity,  and  much  less  frequently  than  in  other 
cases  with  correspondingly  equal  metabolism. 

The  Discharge  of  Urine  During  Pregnancy. — The  pressure 
of  the  growing  uterus  upon  the  bladder,  especially  when  the 
patient  is  upright,  makes  frequent  emptying  of  the  bladder 
necessary  in  the  pregnant  woman.  This  disturbance  is  most 
pronounced  in  the  early  and  the  last  months  of  pregnancy. 
The  mucous  membrane  is  congested,  sensitive  and  irritable, 
and  during  the  very  last  of  pregnancy,  in  primipara,  when 
descent  develops,  the  neck  of  the  bladder  may  be  pressed 


96  MANUAL   OF   OBSTETRICS 

upon  by  the  descending  head  and  the  urethra  partially  com- 
pressed between  the  head  and  the  symphysis.  So  great  may 
be  the  pressure  in  multiparous  patients  in  whom  the  tissues 
are  relaxed,  that  the  involuntary  discharge  of  urine  is  not 
infrequent.  This  may  follow  lifting  a  heavy  weight,  vom- 
iting, coughing  or  sneezing.  Should  retention  of  urine  occur 
during  pregnancy  it  should  lead  to  the  suspicion  that  there 
is  pressure  upon  the  neck  of  the  bladder,  preventing  the  com- 
plete discharge  of  its  contents. 

Weight  and  Temperature. — Aside  from  the  increased 
weight  of  the  fetus  the  healthy  mother  becomes  heavier  as 
pregnancy  advances.  This  is  probably  caused  by  the  actual 
increase  in  the  maternal  tissues  following  the  stimulation  to 
nutrition  occasioned  by  pregnancy.  In  healthy  patients  the 
temperature  of  the  body  is  correspondingly  raised. 

The  Skin. — The  skin  and  its  appendages  are  considerably 
altered  during  gestation.  In  proportion  to  the  patient's 
complexion,  pigmentation  in  the  skin  may  become  very 
pronounced.  When  this  forms  upon  the  face  in  an  irregular 
mask,  usually  a  yellowish-brown,  it  is  termed  the  chloasma 
of  pregnancy.  No  treatment  has  proved  efficient  in  pre- 
venting or  modifying  this  appearance,  and  it  disappears 
when  pregnancy  ends.  Pigmentation  about  the  breasts, 
on  the  abdomen,  and  about  the  external  genital  organs, 
is  often  observed.  The  skin  often  acts  freely  in  pregnant 
women,  and  an  acid  and  irritating  perspiration  may  disturb 
the  patient's  comfort.  In  women  who  have  any  tendency 
to  gout  the  hair  may  come  out  in  considerable  quantities  dur- 
ing pregnancy.  In  patients  who  are  in  good  condition,  the 
hair  is  but  little  if  at  all  affected,  and  often  improves  con- 
siderably during  gestation. 

Few  pregnant  patients  escape  trouble  with  the  teeth. 
There  is  softening  and  exposure  of  the  nerve  to  irritants,  with 
resulting  pain,  which  may  greatly  distress  and  disturb  the 
patient.  The  teeth  should  be  examined  in  early  pregnancy, 
and  again  from  time  to  time  as  gestation  advances.  No 
severely  painful  dental  operations  should  be  practised  upon 
pregnant  women,  but  palliative  measures  are  indicated  until 
pregnancy  is  over. 


THE    PHYSIOLOGY    OF    PREGNANCY  97 

The  Skeleton. — The  entire  skeleton  increases  considerably 
during  gestation,  and  in  healthy  patients  never  returns  to  its 
former  dimensions.  Bones  grow  normally  by  the  increased 
deposit  of  tissue  at  the  epiphyses.  In  patients  who  have 
been  slender  and  poorly  developed,  pregnancy  may  result  in 
a  very  considerable  increase  in  the  capacity  of  the  pelvis  and 
of  the  thorax  as  well. 

The  Nervous  System. — Increased  reflex  excitability  is 
characteristic  of  pregnancy.  This  is  seen  in  disturbance  of 
the  pulse,  fainting  and  giddiness,  change  in  facial  color,  in 
the  action  of  the  heart  and  the  pulse,  susceptibility  to  cold 
and  heat,  and  disturbance  in  the  condition  of  the  mind.  The 
latter  may  not  be  severe  enough  to  constitute  actual  disease, 
yet  it  renders  the  patient  unduly  sensitive  to  mental  im- 
pressions. Under  favorable  conditions  the  patient  may  be 
unusually  buoyant  and  even  exhilarated. 

Sleep  may  be  disturbed  in  later  pregnancy  by  the  move- 
ment of  the  fetus,  and  at  times  by  the  patient's  condition  of 
apprehension  and  even  melancholy.  The  more  sound  and 
vigorous  the  patient  the  less  is  her  natural  disposition  altered. 

Neuralgia. — Many  pregnant  women  in  good  average 
health  suffer  considerably  from  iieuralgia.  This  may  follow 
the  altered  state  of  the  blood  in  early  gestation,  and  in  later 
pregnancy  pressure  of  ihe  presenting  part  upon  nerve  trunks 
passing  the  pelvis  may  favor  this  condition.  As  pregnancy 
grows  to  a  close  the  pressure  of  the  presenting  part  may  cause 
pain  in  the  pelvic  nerves,  sometimes  extending  downward 
upon  the  thighs. 

In  general,  healthful  pregnancy  means  stimulation  to 
all  the  normal  processes  of  the  body,  with  increased  nutrition 
and  correspondingly  increased  demands  upon  the  processes 
of  assimilation  and  excretion. 


CHAPTER  IX 
THE  HYGIENE  OF  PREGNANCY 

By  the  hygiene  of  pregnancy  is  meant  such  care  as  should 
be  given  every  pregnant  woman  independently  of  the  de- 
velopment of  diseased  conditions. 

THE  EARLY  MONTHS 

During  early  pregnancy  patients  in  good  general  condition 
may  experience  marked  disinclination  to  exertion,  with  a  de- 
sire for  rest  and  quiet.  When  one  remembers  that  at  this 
time  the  fetal  tissues  are  growing  most  rapidly  and  that  the 
mother's  organism  is  resisting  excessive  fetal  growth,  and 
that  her  strength  is  necessary  for  this  process,  the  apathetic 
state  of  early  pregnancy  becomes  intelligible.  Patients  are 
often  urged  to  exert  themselves  in  early  pregnancy,  and  a  far 
more  rational  course  would  be  to  give  them  abundant  rest 
and  quiet,  with  plenty  of  easily  digested  nourishment.  When 
it  is  found  that  the  patient  is  not  hysterical  or  lazy,  her  crav- 
ing for  rest  should  be  considered  natural  and  should  be  grati- 
fied. The  disturbance  of  the  digestive  organs  suggests  that 
large  quantities  of  food,  difficult  of  digestion,  should  be 
avoided,  and  that  the  patient  should  often  be  given  the  light- 
est and  most  digestible  sorts  of  food.  Those  who  can  take 
milk  should  have  this  frequently  in  any  form  which  is  ac- 
ceptable. The  craving  for  fruit  should  be  gratified,  and  good 
bread  and  butter  should  be  added  to  the  diet.  Broths,  soups, 
green  vegetables,  simple  puddings,  junket,  and  toast,  will  be 
found  useful.  Many  patients  crave  food  frequently,  but  in 
small  quantities,  and  this  craving  should  be  gratified. 

The  patient's  hesitation  in  going  into  crowds  or  where 
she  will  be  observed,  should  also  be  considered  a  rational 
condition,  and  she  should  be  spared  all  annoyance  and  pos- 
sible distress. 


THE   EARLY   MONTHS  99 

In  early  pregnancy,  constipation  is  often  present,  so 
that  especial  attention  should  be  given  to  this.  Compound 
licorice  powder,  cascara,  phenolphthalein,  senna  or  senna 
leaves,  laxative  cereal  foods,  raw  or  cooked  fruit,  cream,  and 
olive  oil,  may  all  be  employed,  to  prevent  constipation.  An 
abundant  supply  of  cool  pure  water  is  essential.  Should 
these  means  fail,  enemata  may  be  used  for  a  short  time, 
those  containing  warm  soap-suds  and  olive  oil  being  es- 
pecially useful. 

During  the  early  months  it  is  especially  important  that 
the  patient  adjust  her  clothing  suitably.  The  uterus  cannot 
rise  naturally  out  of  the  pelvis  unless  pressure  be  removed 
from  the  abdomen.  If  corsets  must  be  worn  they  should  be 
loose,  the  patient  should  be  cautioned  to  empty  the  bladder 
frequently,  and  constipation  must  be  avoided.  It  is  well  to 
substitute  for  the  corsets  a  suitable  waist,  to  whose  lower 
edge  the  underclothing  can  be  attached.  Constriction  of  the 
pelvic  and  abdominal  regions  should  be  entirely  avoided. 
The  clothing  should  be  sufficient  to  protect  the  patient  from 
chill,  and  as  light  as  is  consistent  with  comfort. 

At  this  time  the  patient  is  often  exceedingly  susceptible 
to  cold  and  damp.  Exposure  must  be  avoided,  and  in  time 
of  intense  heat  every  precaution  must  be  taken  to  avoid  sun- 
stroke or  heat-stroke. 

It  is  especially  important  in  the  early  months  to  avoid 
the  interruption  of  pregnancy,  which  constitutes  abortion. 
Any  disturbance  of  whatever  sort  of  the  pelvic  organs  is  to  be 
absolutely  prohibited,  such  as  lifting,  straining,  reaching 
high  above  the  head,  running  a  sewing  machine  with  a  foot 
treadle,  high  steps,  violent  exercise,  travelling  in  an  un- 
comfortable vehicle,  motoring  at  high  speed  over  a  rough 
road,  and  any  situation  exposing  the  patient  to  jar  or  strain 
is  to  be  prevented.  At  the  times  when  menstruation  should 
have  returned,  especial  care  must  be  taken,  and  if  there  be 
signs  of  disturbance  the  patient  should  remain  recumbent 
at  this  period.  An  examination  of  her  urine  should  fre- 
quently be  made,  not  less  often  than  weekly  in  primiparous 
patients,  and  such  examination  should  be  complete.  Writ- 
ten instructions  concerning  diet,  the  care  of  the  digestive 


100  MANUAL   OF   OBSTETRICS 

organs,  and  other  important  matters,  should  be  furnished. 
The  physician  must  see  his  patient  often  enough  to  be  sure  of 
her  condition. 

THE  LATER  MONTHS 

If  the  early  months  have  passed  successfully,  the  later 
months,  especially  the  fifth,  sixth,  seventh  and  eighth  months, 
call  for  moderate  exercise  and  a  much  more  active  life. 
Gentle  exercise  in  the  open  air  to  the  point  of  reasonable 
fatigue  is  of  great  value.  Any  reasonable  exercise  may  be 
taken  and  walking  is  the  best  possible  form.  Those 
entertainments  and  surroundings  which  are  cheerful  and 
not  perturbing  are  of  great  use,  and  the  atmosphere  of 
the  patient's  life  should  be  as  exhilarating  as  possible.  Abun- 
dant sleep  in  the  best  possible  air  is  necessary.  The  clothing 
should  be  so  arranged  as  to  avoid  constriction,  not  only  of 
the  abdomen  but  of  the  lower  limbs  as  well,  to  prevent  the 
development  of  varicose  veins.  The  clothing  should  be  so 
arranged  as  to  permit  the  freest  possible  motion.  In  vigor- 
ous women  the  appetite  often  increases  very  largely,  and 
this  may  be  gratified,  but  with  great  caution,  to  avoid  the 
excessive  use  of  meat.  Experience  has  shown  that  the  fetal 
skeleton  becomes  unusually  large  and  heavy  in  the  children  of 
women  who  eat  meat  in  excess,  while  a  diet  composed 
largely  of  milk,  bread,  fruit  and  vegetables,  favors  the  growth 
and  nutrition  of  the  child  but  does  not  produce  excessive  de- 
velopment of  the  bones. 

To  secure  a  spontaneous  and  successful  birth  the  regula- 
tion of  the  mother's  diet  will  be  found  of  importance. 

As  pregnancy  advances  the  increased  demand  upon  elim- 
ination calls  for  additional  care  in  the  matter  of  diet.  The 
urine  should  be  examined  regularly,  the  pulse  tension  of  the 
patient  observed,  and  the  patient  should  be  instructed  in 
writing  to  report  at  once  to  her  physician,  headache,  dis- 
turbance of  vision,  constipation,  loss  of  appetite,  swelling  of 
the  limbs  or  face,  and  unusual  movements  of  the  fetus.  The 
reappearance  of  menstruation  or  hemorrhage  from  the  gen- 
ital tract  must  be  brought  immediately  to  the  physician's 
attention. 


THE    END    OF    PREGNANCY  101 

THE  LAST  WEEKS  OF  PREGNANCY 

The  patient  should  be  told  concerning  the  phenomena  of 
the  last  weeks  of  pregnancy  so  that  she  may  observe  and  re- 
port the  descent  of  the  fetus,  increased  pressure  upon  the 
bladder  or  bowel,  swelling  of  the  limbs,  and  increased  or 
lessened  movement  of  the  fetus.  Unless  she  has  with  her  a 
friend,  nurse,  or  experienced  person,  she  should  be  instructed 
in  the  character  of  labor  pains,  so  that  she  may  recognize 
those  which  are  genuine  and  summon  help  in  time,  and  not 
be  mistaken  concerning  those  pains  which  are  not  the  be- 
ginning of  labor. 

THE  GENERAL  HYGIENE  OF  PREGNANCY 

Too  often  pregnancy  comes  unwelcome  to  the  patient  who 
is  fully  occupied  with  other  matters.  In  such  cases  she  en- 
deavors to  pursue  her  usual  occupations,  giving  to  the  grow- 
ing fetus  such  strength  or  energy  as  may  be  left.  It  is  ob- 
vious that  in  these  cases  one  cannot  expect  the  best  possible 
development  in  the  child  under  the  conditions  present. 

Where  the  patient  accepts  pregnancy  gladly  and  is  willing 
to  order  her  life  accordingly,  a  corresponding  development 
and  vigor  will  be  found  in  the  child.  It  has  long  been  be- 
lieved that  pregnant  patients  should  avoid  everything  which 
is  disturbing.  The  ancients  believed  that  by  surrounding 
the  patient  with  beautiful  objects  the  development  and  sym- 
metry of  the  child  was  greatly  enhanced.  Unquestionably 
the  mental  condition  of  the  mother  has  an  important  bearing 
upon  the  development  of  the  nervous  system  of  the  infant. 
Such  precautions  are  usually  followed  with  a  corresponding 
beneficial  result. 

THE  END  OF  PREGNANCY 

To  compute  the  probable  time  of  confinement,  it  is  first 
necessary  to  accurately  obtain  the  date  of  the  end  of  the  last 
normal  menstruation.  In  questioning  the  patient,  care 
should  be  taken  to  emphasize  the  word,  normal  or  natural,  in 
speaking  of  menstruation.  A  period  considerably  less  than 
the  average  indicates  that  conception  has  occurred  just  be- 
fore menstruation;  270  days  from  the  date  of  the  last  men- 


102  MANUAL   OF   OBSTETRICS 

struation  will  give  the  patient  the  probable  average  time  of 
confinement  in  the  first  two  or  three  of  her  pregnancies. 
After  this,  between  270  and  280  days  should  be  obtained  by 
actual  count  from  the  end  of  the  last  menstruation. 

The  descent  and  engagement  of  the  child  in  primiparous 
patients  indicate  that  pregnancy  is  very  near  its  close.  If 
more  accurate  information  is  desired  a  vaginal  examination 
to  determine  the  condition  of  the  cervix  and  the  presence  or 
absence  of  descent  of  the  fetus,  will  be  found  useful.  Physi- 
cal examination  at  the  end  of  pregnancy  is  more  reliable 
than  the  computation  of  days. 


r.    • 

»'  j    I  )     ''       I       I   r 


CHAPTER  X 

THE  MATERNAL  AND  FETAL  PATHOLOGY  OF 
PREGNANCY 

Pregnancy  brings  about  such  great  changes  in  the  mother's 
organism  that  but  very  slight  variations  suffice  to  produce 
pathological  conditions.  Of  these  the  most  common  and 
one  of  the  most  important  is  the  toxemia  of  pregnancy. 

THE  TOXEMIA  OF  PREGNANCY 

It  has  long  been  known  that  a  warm-blooded  animal  may 
destroy  its  own  life  through  the  absorption  of  poisons  pro- 
duced by  the  waste  of  its  own  tissue.  Death  from  starvation 
is  an  example  of  this,  and  in  acute  conditions  sunstroke  and 
heatstroke  illustrate  its  pathology. 

In  the  pregnant  woman  the  presence  of  the  embryo  and 
fetus  gives  rise  to  substances  poisonous  to  the  mother,  in 
addition  to  those  formed  in  her  own  tissues. 

While  numerous  theories  have  been  advanced  to  account 
for  the  toxemia  of  early  pregnancy,  it  seems  most  rational  to 
ascribe  it  to  the  absorption  of  substances  formed  by  the  em- 
bryo and  fetus  in  addition  to  those  produced  by  the  waste  of 
the  mother's  body  itself.  These  poisons,  whether  fetal  or 
maternal,  are  called  toxins,  and  the  condition  produced  by 
their  absorption  is  known  as  toxemia. 

Signs  and  Symptoms. — The  important  signs  and  symptoms 
of  the  toxemia  of  early  pregnancy  are  those  indicated  by  dis- 
turbances in  digestion  and  assimilation,  an  altered  state  of 
the  blood,  and  as  a  result  the  nausea  and  vomiting  of  the 
earl}-  morning  becoming  exaggerated,  the  sensation  of  nausea 
persisting  throughout  the  patient's  waking  hours.  Ac- 
companying this  is  great  prostration,  loss  of  appetite,  a 
heavy  lethargic  sleep  later  giving  place  to  unpleasant  dreams 
and  restlessness,  the  failure  to  retain  anything  upon  the 

103 


104  MANUAL    OF    OBSTETRICS 

stomach,  obstinate  constipation,  and  substernal  pain  ex- 
tending from  the  epigastrium.  The  pulse  is  rapid  and  grows 
progressively  weak,  respiration  is  sluggish,  and  as  the  dis- 
ease progresses  the  matter  ejected  from  the  bowel  contains 
an  abundance  of  disintegrated  blood  cells  which  resemble 
coffee-grounds.  Similar  material  is  discharged  from  the 
bowel.  The  urine  is  diminished  greatly  in  quantity,  with 
high  specific  gravity,  frequently  albuminous,  and  often  con- 
tains epithelial  or  granular  casts.  The  nitrogen  partition 
shows  greatly  lessened  urea  with  corresponding  increase  in 
creatin  and  creatinin,  the  rest  nitrogen  is  increased,  and  in- 
dican  is  present.  Casts  of  various  sorts  are  often  found. 
As  the  disease  progresses  the  patient  in  some  cases  becomes 
greatly  emaciated,  in  others  there  is  considerable  deposit  of 
fat,  the  action  of  the  heart  is  progressively  rapid  and  weak, 
frequently  becoming  thready  and  irregular.  The  mouth 
and  gums  become  covered  with  sordes,  the  odor  about  the 
patient  is  offensive,  and  the  skin  is  in  places  the  site  of  a  pur- 
puric  or  hemorrhagic  condition.  The  patient's  general  con- 
dition resembles  that  of  the  third  or  fourth  week  of  a  severe 
typhoid.  In  fatal  cases  life  usually  terminates  in  exhaustion 
without  convulsions  or  delirium. 

In  cases  which  do  not  go  to  a  fatal  termination  the  symp- 
toms gradually  subside,  the  patient  is  able  to  take  and  as- 
similate food,  and  her  general  strength  returns. 

The  Diagnosis  of  Pernicious  Nausea  and  Vomiting. — In 
making  this  diagnosis  the  physician  must  remember  that  two 
classes  of  patients  are  especially  apt  to  mislead :  One  is  those 
who  are  hysterical,  in  whom  the  nausea  and  vomiting  are 
entirely  neurotic,  and  in  whom  the  condition,  while  appar- 
ently serious,  is  not  really  dangerous. 

Another  class  of  cases  is  those  which  mislead,  and  encourage 
nausea  and  vomiting  in  early  pregnancy,  exaggerating  the 
symptoms  with  the  hope  that  the  physician  may  be  induced 
to  perform  therapeutic  abortion. 

To  distinguish  between  patients  who  are  really  in  a  seri- 
ous condition  and  those  who  are  nervously  disturbed,  a 
careful  physical  examination  of  the  patient  is  necessary. 
The  action  of  the  heart  and  the  condition  of  the  pulse  in 
those  really  ill  give  a  favorable  indication.  The  action  and 


THE    TOXEMIA    OF   PREGNANCY  105 

sounds  of  the  heart  are  duller  and  weaker  than  normal,  the 
pulse  is  small,  feeble,  irregular  and  often  very  rapid.  The 
general  condition  is  one  of  extreme  apathy,  and  this  is  present 
when  the  patient  is  left  entirely  alone  or  when  she  realizes 
that  no  one  is  observing  her.  Efforts  to  rouse  her  by  mental 
stimulation  fail,  and  it  becomes  evident  that  the  patient  is 
really  self-poisoned.  This  is  confirmed  by  the  examination 
of  the  urine,  and  of  especial  importance  is  the  examination 
of  the  blood.  Such  will  show  in  the  urine  a  greatly  lessened 
urea  percentage  and  high  ammonia  coefficient,  with  increase 
in  other  nitrogenous  bodies.  Examination  of  the  blood  finds 
the  red  cells  much  altered  and  broken  down,  with  blood 
coloring  matter  free  in  irregular  masses. 

Microscopically  the  urine  may  contain  a  considerable 
number  of  epithelial  or  granular  casts.  The  total  quantity 
of  urine  is  greatly  diminished.  There  is  progressive  loss  of 
weight,  and  almost  or  entirely  complete  inability  to  retain 
and  assimilate  nourishment.  There  is  great  tenderness  over 
the  epigastrium,  and  a  burning  and  constant  pain  beneath 
the  sternum.  The  mental  state  of  the  patient  is  apathetic. 

In  contrast  the  nervous  patient  is  often  cured  by  sugges- 
tion,— by  ascertaining  what  would  be  most  agreeable  and 
desirable  for  her,  and  by  proposing  such  a  change  in  her  en- 
vironment or  surroundings.  A  very  simple  remedy,  such  as 
a  hypodermatic  injection  of  water,  may  produce  good  results. 
Removing  the  patient  from  irritating  or  depressing  surround- 
ings has  often  resulted  in  rapid  cure;  putting  the  patient  at 
rest,  and  giving  proper  feeding  frequently  causes  the  symp- 
toms to  disappear. 

In  patients  who  are  endeavoring  to  deceive  the  physician, 
an  opinion  as  to  the  severity  of  the  case  must  not  be  given 
until  there  has  been  abundant  opportunity  to  examine  the 
blood,  the  urine,  and  to  give  the  patient  a  complete  physical 
investigation.  While  the  patient's  statements  need  not  be 
openly  rejected,  no  reliance  should  be  placed  upon  them. 

The  Differential  Diagnosis. — Pregnancy  must  first  be 
demonstrated.  If  care  is  not  taken  to  establish  this  fact 
grave  errors  may  result.  Patients  have  been  treated  for 
gastritis  and  gastric  ulcer,  for  hemorrhage  from  the  kidneys, 
for  tumor  of  the  brain,  for  nephritis,  and  for  malignant  dis- 


106  MANUAL   OF    OBSTETRICS 

ease  of  the  uterus,  when  the  condition  really  causing  the  symp- 
toms was  the  toxemia  of  pregnancy. 

Pregnancy  established,  we  must  next  distinguish  between 
hysterical  nausea  and  vomiting  and  acute  toxemia. 

In  hysterical  nausea  and  vomiting  the  patient's  heart 
action  and  pulse,  while  easily  disturbed,  remain  good.  When 
the  nervous  system  is  freed  from  depressing  influences,  and 
when  the  mind  is  soothed  and  stimulated  the  patient  grows 
better. 

To  make  a  complete  diagnosis  the  patient  must  be  put 
under  intelligent  observation,  the  condition  of  the  digestive 
organs  looked  after,  and  the  patient  supplied  with  easily 
digested  food.  The  urine  will  be  found  slightly  altered,  if 
at  all,  the  nitrogen  partition  of  the  urine  will  show  a  reason- 
ably high  percentage  of  urea,  while  the  ammonia,  rest  and 
creatinin  nitrogen  will  be  low.  The  examination  of  the 
blood  will  show  moderate  leukocytosis  and  no  disintegration 
among  the  red  cells.  The  urine  will  not  contain  epithelial 
blood  or  fat  casts,  and  the  matter  ejected  from  the  stomach 
and  the  bowel  movements  will  not  contain  disintegrated 
blood. 

In  acute  toxemia  in  the  early  months  the  patient's  nausea 
will  be  constant  and  will  become  pernicious.  Food  cannot 
be  retained,  the  quantity  of  urine  will  be  scanty,  the  urea 
nitrogen  low  and  the  ammonia,  rest  and  creatinin  nitrogen 
high.  There  will  be  epithelial,  blood  or  fat  casts;  the  blood 
will  show  increased  leukocytosis,  and  Abderhalden's  serum 
test  of  pregnancy  will  give  increased  evidence  of  disturbed 
nitrogenous  metabolism.  As  the  case  becomes  severe  the 
red  blood  cells  will  be  found  disintegrated  and  crystals  of 
hematin  will  be  present  in  considerable  quantities. 

The  patient's  mental  condition  will  be  apathetic,  sordes 
will  form  upon  the  mouth  and  teeth,  the  abdomen  will  be- 
come scaphoid,  emaciation  will  occur;  or  the  patient  may 
remain  plump  but  fat  and  flabby.  There  will  be  substernal 
pain,  and  there  may  be  considerable  hemorrhage  from  the 
stomach,  bowels  and  the  mucous  membrane  of  the  mouth,  or 
beneath  the  skin.  Death  will  ensue  from  disintegration  of 
the  heart  muscle  or  cerebral  hemorrhage. 

When  acute  toxemia  with  pernicious  nausea  is  caused 


THE  TOXEMIA  OF  PREGNANCY  107 

by  the  overgrowth  of  syncytium  the  symptoms  may  be  diffi- 
cult to  interpret.  Upon  the  clinical  picture  of  pernicious 
nausea  will  be  grafted  evidences  of  malignant  growth  in  the 
important  viscera.  If  the  brain  and  its  membranes  be  in- 
volved there  will  be  obstinate  pain  and  sometimes  active  de- 
lirium. If  the  lungs  are  the  site  of  metastases  there  will  be 
altered  respiration,  pulmonary  cough  and  perhaps  expectora- 
tion. If  the  abdominal  viscera  be  attacked  the  liver  will  slowly 
enlarge  and  there  will  be  evidences  of  acute  malignant  tox- 
emia. 

The  differential  diagnosis  of  acute  toxemia  in  early 
pregnancy  with  pernicious  nausea  is  important,  because  in 
genuine  and  severe  cases  pregnancy  must  be  promptly  ter- 
minated. The  responsibility  for  performing  therapeutic 
abortion  is  great,  and  the  decision  to  take  this  important  step 
requires  accurate  knowledge  and  good  judgment,  and  may 
also  render  necessary  consultation. 

Pathology. — In  acute  toxemia  in  early  pregnancy  the  most 
characteristic  pathological  changes  will  be  found  in  the  blood 
and  in  the  viscera  connected  with  metabolism.  In  the  blood 
disintegration  of  blood  cells,  the  presence  of  free  hematin, 
leukocytosis,  and  a  highly  poisoned  condition  of  the  blood 
serum,  demonstrable  by  injection  into  animals,  will  be  pres- 
ent. In  the  viscera  connected  with  metabolism  the  mucous 
membrane  of  the  stomach  and  intestine  will  show  degenerate 
changes  and  multiple  hemorrhage.  In  the  liver  interstitial 
hemorrhage  into  the  lobules  is  characteristic.  The  small 
vessels  are  plugged  with  hematin  and  the  liver  substance  is 
stained.  Similar  appearances  in  the  spleen  in  less  degree  are 
also  seen.  In  the  kidneys  the  epithelia  undergo  granular 
and  fatty  changes,  the  capillaries  rupture,  and  free  hematin 
is  present.  The  thyroids  and  suprarenals  may  show  a  similar 
change.  Hemorrhagic  pancreatitis  may  be  present. 

The  bone  marrow  shows  degenerative  changes,  the  sub- 
cutaneous fat  disappears  or  becomes  brightly  stained  with 
bilirubin  or  biliverdin,  the  periosteum  upon  the  inferior 
surface  of  the  sternum  may  be  swollen  and  dark,  and  the 
connective  tissue  beneath  the  sternum  engorged  and  altered. 
The  capillaries  of  the  lungs  undergo  minute  rupture,  the 
pleurae  are  altered,  and  turbid  straw-colored  fluid  may  be 


108  MANUAL   OF   OBSTETRICS 

found  in  the  pleural  sacs.  In  the  brain  a  condition  similar  to 
that  observed  in  the  lungs  and  their  serous  membranes  may 
be  present.  In  hemorrhagic  cases  considerable  areas  of  ne- 
crosis may  be  observed  hi  the  mucous  membrane  of  the 
stomach  and  bowels  and  in  the  kidneys,  and  rarely  in  the 
bladder.  When  petechial  eruptions  are  present  the  small 
vessels  of  the  skin  rupture,  the  muscular  tissues  become  wasted 
or  degenerated,  the  muscles  showing  cloudy  and  granular 
conditions;  nerve  cells  exhibit  granular  changes  and  the 
neurilemma  may  give  evidence  of  degeneration.  In  albumi- 
nuric  cases  hemorrhages  into  the  retinae  are  not  infrequent. 
In  some  patients  the  veins  of  the  esophagus  may  be  consid- 
erably distended  and  their  rupture  may  cause  hemorrhage. 

Prognosis. — In  pseudo-hysterical  nausea  and  vomiting  in 
early  pregnancy,  the  prognosis,  so  far  as  recovery  is  concerned, 
is  good.  Such  cases  are  sometimes  difficult  to  manage,  as 
some  of  them  are  illegitimately  pregnant  and  the  condition 
must,  if  possible,  be  concealed. 

In  genuine  acute  toxemia  of  early  pregnancy  with  perni- 
cious nausea  the  prognosis  is  always  guarded.  Unless  com- 
plete control  of  the  patient  can  be  obtained,  and  elimination 
and  nutrition  promptly  stimulated,  the  patient  may  rapidly 
pass  into  a  condition  where  pregnancy  must  be  interrupted. 
Neglected  cases  of  acute  toxemia  in  pregnancy  frequently  die. 

Treatment. — The  treatment  of  hysterical  nausea  and  vom- 
iting of  early  pregnancy  simulating  toxemia  consists  in  rest, 
stimulation  of  the  eliminative  organs,  systematic  and  careful 
feeding,  and  mental  treatment  by  suggestion.  The  improve- 
ment is  usually  rapid,  when  the  patient  should  be  advised 
to  take  up  her  normal  life  as  quickly  as  her  strength  will  per- 
mit, being  careful  to  avoid  excitement  and  over-fatigue. 
Especial  attention  should  be  paid  to  nutrition  and  excretion 
until  pregnancy  is  well  established  and  the  placenta  has  fully 
formed. 

In  acute  toxemia  with  pernicious  nausea,  the  mistake 
is  often  made  of  attempting  to  treat  the  patient  without  com- 
plete control.  Unless  the  patient  be  under  constant  and 
accurate  observation  she  may  rapidly  drift  into  a  hopeless 
condition  before  the  physician  realizes  the  gravity  of  the 
situation. 


THE  TOXEMIA  OF  PREGNANCY  109 

Such  patients  require  isolation  and  trained  nursing.  The 
action  of  the  heart  should  be  steadied  and  stimulated  by 
strychnia  and  digitalin  given  hypodermatically.  If  there  is 
much  nervous  excitement  or  restlessness,  to  this  should  be 
added  codein  in  appropriate  doses. 

If  foul  material  has  been  ejected  from  the  stomach,  co- 
pious gastric  lavage  is  indicated.  This  should  preferably  be 
with  a  warm  saturated  solution  of  bicarbonate  of  sodium  using 
fluid  in  abundance  until  the  return  flow  is  perfectly  clear; 
eight  ounces  to  one  pint  should  then  be  left  in  the  stomach  for 
absorption.  Once  in  twenty-four  hours  the  colon  should  be 
thoroughly  flushed  with  normal  salt  solution,  no  limit  being 
placed  upon  the  amount  employed.  The  fluid  should  return 
clear  and  a  pint  should  then  be  left  in  the  bowel  for  absorp- 
tion. If  the  action  of  the  heart  is  reasonably  good,  and  the 
heart  muscle  is  able  to  deal  with  increased  fluid,  eight  ounces 
of  salt  solution  should  be  given  by  bowel  every  four  to  six 
hours.  Where  the  presence  of  the  catheter  is  well  tolerated, 
salt  solution  may  be  given  by  the  continuous  method  for 
two-hour  periods. 

Every  effort  must  be  made  to  sustain  the  patient  or  to  re- 
inforce the  condition  of  the  blood.  For  several  days,  at 
first,  the  patient  must  be  nourished  and  sustained  by  nutri- 
ent enemata  containing  peptonized  milk,  panopeptone,  raw 
eggs  beaten  up,  and  brandy  or  whiskey.  This  requires  very 
skilful  and  conscientious  nursing,  and  care  must  be  taken  to 
so  adjust  the  injection  of  salt  solution  and  rectal  feeding  that 
the  bowel  does  not  become  irritable,  and  reject  what  is  given. 
To  maintain  the  patient's  body  heat,  the  skin  should  be 
cleansed  with  warm  soap  and  water  and  the  patient  placed 
between  blankets.  In  hot  weather,  alcohol  and  water  spong- 
ing should  be  used.  An  abundant  supply  of  oxygen  by  open 
windows  or  by  direct  inhalation  is  useful. 

The  patient  must  be  put  at  absolute  rest  and  disturbed 
as  little  as  possible.  It  is  well  to  avoid  hypodermoclysis 
because  of  the  tendency  to  subcutaneous  extravasation  and 
hemorrhage.  Benefit  has  been  occasionally  seen  by  lowering 
the  patient's  head  and  raising  the  remainder  of  the  body  con- 
siderably. A  hot  water  bottle  covered  with  flannel  placed 
beneath  the  cerebellum  may  prove  stimulating.  A  hot  water 


110  MANUAL    OF    OBSTETRICS 

bottle  or  dry  ice-bag  placed  over  the  epigastrium  may  re- 
lieve some  of  the  patient's  painful  sensations. 

If  the  patient  grows  better  a  cautious  effort  may  be  made 
to  give  nourishment  by  the  mouth.  Peptonized  milk,  or- 
ange, grape  fruit,  lemon,  or  pine-apple  albumen,  beef  juice, 
gruels  and  whiskey  or  brandy,  may  be  tried.  These  patients 
often  crave  nourishment  persistently,  and  such  must  be  given 
every  hour  or  two  in  small  quantities.  Whatever  drugs  are 
used  should  be  given  by  hypodermatic  injection,  and  the 
functions  of  the  stomach  utilized  for  nourishment  only. 

The  Interruption  of  Pregnancy. — If  upon  thorough  and 
conscientious  care  improvement  does  not  occur,  and  the 
examination  of  the  blood  and  urine  and  physical  examina- 
tion of  the  heart  shows  no  gain,  but  slight  loss,  pregnancy 
must  be  interrupted. 

For  this  purpose  ether,  largely  diluted  with  oxygen  or  car- 
bondioxid,  should  be  employed.  The  patient  should  be 
disturbed  as  little  as  possible  and  elaborate  preparation  of 
the  patient  is  unnecessary.  Copious  gentle  irrigation  with 
one  per  cent,  lysol  is  sufficient. 

The  cervix  should  be  drawn  down  and  dilated  with  solid 
dilators  until  a  large  blunt  spoon  curette  can  be  introduced. 
This  should  then  be  passed  over  the  surface  of  the  uterus, 
and  if  possible  the  ovum  be  thoroughly  broken  up.  The 
uterus  should  then  be  packed  tightly  with  sterile  or  10  per 
cent,  iodoform  gauze  and  the  vagina  moderately  tamponed 
with  sterile  gauze.  The  whole  procedure  should  be  done  as 
gently  and  quickly  as  possible,  no  effort  being  made  to  curette 
away  the  ovum.  Nausea  usually  ceases  at  once,  and  on  the 
removal  of  the  gauze  in  forty-eight  to  seventy-two  hours,  the 
ovum  is  found  adherent  to  it,  or  soon  afterward  expelled. 

Treatment  by  Counter-irritation  of  the  Cervix. — In  some 
cases  of  hysterical  vomiting  of  pregnancy  immediate  control 
of  the  case  has  been  obtained  by  painting  the  cervix  with 
iodine  or  by  moderately  dilating  the  cervix.  In  these  cases 
an  irritable  condition  of  the  cervical  mucous  membrane,  or  a 
tightly  contracted  os,  which  did  not  soften  naturally,  has 
been  the  irritating  cause  which  kept  up  the  nervous  dis- 
turbance. In  acute  toxemia  such  procedures  are  useless. 


THE   TOXEMIA    OF   LATER   PREGNANCY  111 

Complications. — In  acute  toxemia  of  early  pregnancy,  al- 
though the  ovum  may  have  been  expelled,  fatal  hemorrhage 
may  occur  at  any  time  within  two  weeks  following  the  termi- 
nation of  pregnancy.  An  effort  should  be  made  to  control 
such  bleeding  by  tamponing  the  uterus  again,  and  by  tightly 
packing  the  vagina.  This  effort  is  rarely  successful,  and 
secondary  hemorrhage  in  these  cases  is  usually  fatal. 

The  Effect  Upon  the  Ovum  of  the  Acute  Toxemia  of  Early 
Pregnancy. — In  hysterical  nausea  and  vomiting  of  early 
pregnancy  the  growth  and  development  of  the  embryo  are 
influenced  surprisingly  little.  The  patient  usually  goes  to 
full  term  and  the  fetus  will  show  no  result  of  the  mother's 
condition  except  an  inherited  instability  of  the  nervous  sys- 
tem. 

In  acute  toxemia,  independently  of  the  interruption  of 
pregnancy,  hemorrhage  frequently  occurs  into  the  ovum 
from  the  decidua  and  into  the  chorion.  Such  apoplexies 
may  destroy  the  life  of  the  embryo  and  blight  the  ovum. 
Such  may  be  retained  in  the  uterus  for  several  weeks  and 
finally  expelled.  The  patient's  symptoms  often  grow  mark- 
edly better  with  the  death  of  the  embryo,  so  that  sudden 
spontaneous  improvement  may  be  taken  as  a  sign  of  em- 
bryonal death.  Retention  of  such  an  ovum  is  dangerous 
because  its  syncytium  may  grow  luxuriously  and  produce 
syncytioma  malignum. 

THE  TOXEMIA  OF  LATER  PREGNANCY 

After  the  formation  of  the  placenta  toxemia  does  not  so 
often  produce  pernicious  nausea,  but  may  cause  the  other 
conditions  described,  culminating  in  acute  fulminant  tox- 
emia, sometimes  called  eclampsia  without  convulsions  or 
eclamptic  seizures.  In  these  cases  the  blood  becomes  ex- 
cessively poisonous,  the  blood  serum  rapidly  destroying 
animals  into  which  it  is  injected.  Disintegration  of  the 
blood  ensues.  The  walls  and  the  vessels  of  the  endocardium 
and  heart  muscle  undergo  acute  degenerative  changes;  the 
liver  and  other  organs  of  assimilation  show  parenchymatous 
hemorrhage;  in  the  brain  hyperemia  or  acute  anemia  with 
multiple  hemorrhage,  edema  of  the  ventricles  and  acute  de- 
generation of  nerve  cells,  are  observed.  Should  pregnancy 


112  MANUAL    OF    OBSTETRICS 

terminate  the  patient  may  succumb  from  multiple  pulmon- 
ary hemorrhage  with  minute  areas  of  gangrene,  the  decidua 
becomes  extensively  degenerated,  and  the  normally  implanted 
placenta  may  separate  in  varying  extent,  causing  hemorrhage 
which  may  be  concealed  or  apparent.  Degenerative  changes 
in  the  epithelia  of  the  kidneys  with  hemorrhage,  may  greatly 
impair  their  function,  lessen  the  quantity  of  urine,  and  pro- 
duce serum  albumen  in  excess,  with  casts  in  the  urine. 

In  fulminant  toxemia  the  patient  is  seized  with  intense 
epigastric  pain,  with  violent  vomiting,  or  very  severe  nausea 
and  syncope;  the  circulation  is  greatly  depressed,  there  may 
be  hemorrhages  from  the  stomach,  bowel,  or  from  the  uterus, 
following  placental  separation.  Death  may  ensue  without 
convulsions  from  rapid  granular  degeneration  of  the  heart 
muscle  or  from  cerebral  hemorrhage. 

When  the  resisting  power  of  the  patient  is  greater,  Nature 
may  endeavor  to  save  her  life  by  producing  convulsions. 
Such  are  epileptiform,  clonic,  tonic,  and  are  often  accom- 
panied by  active  uterine  contractions  which  terminate  preg- 
nancy. Should  labor  fail,  convulsions  may  hasten  the 
patient's  death  by  overburdening  the  heart,  paralyzing  the 
respiratory  centre  and  causing  acute  cerebral  edema  or  hem- 
orrhage. Should  toxemia  persist  after  the  uterus  is  emptied, 
pulmonary  hemorrhage  and  gangrene  must  be  feared. 

Diagnosis. — The  diagnosis  of  the  toxemia  of  later  preg- 
nancy is  less  often  marked  by  nervous  symptoms  than  in  the 
earlier  months.  The  mind  is  usually  disturbed  and  the 
patient  is  melancholic,  apathetic  or  sleepless  and  intensely 
irritable.  In  proportion  to  the  resisting  power  of  the  patient 
the  pulse  tension  is  greatly  increased  or  much  lowered.  A 
moderately  high  pulse  tension  is  a  more  favorable  sign.  The 
secretions  are  noticeably  diminished  in  quantity  and  altered 
in  quality.  The  secretory  nerves  are  paretic  or  paralyzed; 
the  skin  may  be  dry  or  greatly  relaxed,  with  clammy  perspira- 
tion; the  tongue  is  usually  furred  and  coated,  often  flabby, 
sometimes  resembling  the  tongue  of  a  typhoid  patient.  In 
moderate  degree  jaundice  may  be  present. 

The  fetal  movements  are  sometimes  unusually  active, 
the  fetal  heart  sounds  more  rapid  and  often  more  weak  than 
normal.  If  convulsions  occur  they  are  epileptiform  in 


THE   TOXEMIA    OF    LATER   PREGNANCY  113 

character  and  tend  to  increase  in  violence  and  frequency  as 
the  case  progresses.  They  sometimes  cease  when  the  uterus 
is  empty,  but  such  is  not  inevitably  the  rule. 

On  examining  the  urine  the  quantity  is  lessened,  its  specific 
gravity  usually  increased,  and  occasionally  diminished. 
The  urine  is  but  little  if  at  all  poisonous  on  injection  into 
animals.  If  the  kidneys  are  greatly  over-burdened,  serum 
albumin  will  be  found  in  excess  and  kidney  debris  of  various 
sorts  may  be  present.  The  nitrogenous  content  of  the  urine 
will  be  altered  in  proportion  to  the  involvement  of  the  liver. 

In  toxemia  of  hepatic  origin  the  urea  will  be  greatly  les- 
sened and  the  ammonia,  rest  and  creatinin  nitrogen  increased. 
Bile  coloring  matter  and  hematin  will  also  be  found. 

The  examination  of  the  blood  will  show  a  moderate  leuko- 
cytosis  with  greater  or  less  disintegration  of  the  red  blood 
cells.  If  fecal  matter  can  be  obtained  for  examination  it  is 
usually  dark  in  color,  often  dried  and  exceedingly  foul  in 
color.  If  the  fluid  which  is  expelled  in  hemorrhage  is  ex- 
amined it  is  dark  in  color,  clots  feebly  in  dark  current  jelly 
masses,  and  is  found  to  contain  an  abundance  of  hematin. 

The  mammary  glands  are  often  turgid,  without  secretion, 
or  yielding  a  thin  and  watery  fluid  or  a  thick  and  intensely 
yellow  material. 

Prognosis. — The  prognosis  of  toxemia  in  the  later  months 
of  pregnancy  must  be  exceedingly  guarded.  In  young  pa- 
tients with  good  heart  action,  where  the  cervix  is  soft,  the 
fetus  low  in  the  pelvis,  in  normal  position,  and  where  labor 
gradually  develops,  the  prognosis  is  fairly  good.  In  older 
patients  with  resisting  cervix,  feeble  heart  action  with 
relaxed  and  flabby  tissues,  the  prognosis  is  far  from  encour- 
aging. 

Treatment. — No  subject  has  occasioned  greater  discussion 
and  in  nothing  is  there  a  wider  difference  of  opinion.  The 
observation  that  the  termination  of  pregnancy  is  often  fol- 
lowed by  the  cessation  of  convulsions,  and  the  fact  that 
many  of  these  cases  are  unrecognized  until  convulsions  occur, 
have  led  to  the  belief  that  immediate  delivery  is  imperative. 
When  one  considers  that  immediate  delivery  does  not  cure 
all  cases,  that  convulsions  are  a  conservative  effort  on  the 
part  of  Nature  to  cause  elimination  and  often  bring  about 

8 


114  MANUAL   OF    OBSTETRICS 

spontaneous  labor,  and  when  it  is  observed  that  a  patient 
at  full  term  may  pass  through  acute  toxemia  with  convul- 
sions without  labor  and  subsequently  give  birth  to  a  living 
child,  it  must  be  admitted  that  the  decision  to  immediately 
deliver  all  cases  is  illogical  and  unwise. 

The  majority  of  observers  at  present  believe  that  the 
first  and  important  step  in  the  toxemia  of  the  later  months  of 
pregnancy  lies  in  prophylaxis.  A  child-bearing  woman 
must  be  instructed  in  the  hygiene  of  pregnancy,  pregnant 
women  must  be  under  personal  observation  by  physicians, 
the  hygiene  of  pregnancy  must  be  strictly  enforced  and  abun- 
dant opportunity  given  for  the  physical  examination  of  the 
patient  and  the  examination  of  the  blood  and  urine.  Could 
these  measures  be  carried  out,  the  toxemia  of  later  pregnancy 
would  rarely  become  dangerous.  When,  however,  through 
neglect  or  otherwise,  toxemia  becomes  acute,  the  most  active 
measures  must  be  taken  to  secure  prompt  elimination.  If 
the  patient  be  stuporous,  with  high  pulse  tension,  whether 
convulsions  have  or  have  not  occurred,  the  most  efficient 
treatment  consists  in  taking  from  a  vein  from  8  to  20  ounces 
of  blood,  followed  by  the  injection  of  from  16  to  32  ounces 
of  warm  normal  salt  solution.  Following  this  the  stomach 
should  be  very  thoroughly  irrigated  with  saturated  solution 
of  bicarbonate  of  sodium  or  normal  salt  solution,  and  from  2^ 
to  5  grains  of  calomel  with  soda  left  in  the  stomach.  The 
colon  should  be  copiously  irrigated  with  warm  salt  solution 
and  from  a  pint  to  a  quart  left  for  absorption.  The  bladder 
must  be  emptied  by  catheter  and  the  urine  saved  for  exam- 
ination. Especial  attention  must  be  paid  to  the  condition 
of  the  heart,  and  digitalin  with  or  without  codein  should  be 
given  hypodermatically.  The  patient  must  be  put  at  abso- 
lute rest,  the  skin  cleansed  with  warm  soap  and  water,  and 
the  patient  covered  with  blankets,  except  in  the  hottest 
weather.  Should  the  skin  be  relaxed  and  clammy,  and  the 
weather  excessively  hot,  sponging  with  alcohol  and  water 
will  be  useful.  Especial  care  must  be  taken  to  protect  the 
patient  from  all  noise  and  irritation.  She  should  be  secluded 
in  a  well  ventilated  room  and  kept,  so  far  as  possible,  at  ab- 
solute rest.  Should  convulsions  occur,  if  excessively  severe, 
they  may  be  controlled  by  the  inhalation  of  oxygen  or  a 


THE   TOXEMIA    OF   LATER   PREGNANCY  115 

small  quantity  of  ether  well  diluted  with  oxygen;  chloroform 
should  not  be  used. 

So  soon  as  eliminative  treatment  has  been  practised,  a 
vaginal  examination  must  be  made  to  determine  the  condi- 
tion of  the  generative  tract.  If  the  cervix  be  completely 
softened  or  obliterated,  if  the  presenting  part  be  low  and 
dilatation  beginning  and  partly  accomplished,  the  mem- 
branes should  be  ruptured.  This  will  be  followed  by  a  period 
of  quiescence  and  then  by  uterine  contractions,  which  may 
cause  convulsions.  If  the  fetus  is  not  expelled  spontaneously 
in  a  reasonable  time,  delivery  should  be  effected  by  the  for- 
ceps or  version.  Moderate  hemorrhage  from  the  uterus 
may  be  permitted  after  delivery.  Realizing  the  possibility 
of  serious  post-partum  hemorrhage  the  uterus  and  vagina 
should  be  tamponed  with  gauze. 

If  the  cervix  be  undilated  and  in  primiparous  patients 
not  softened,  in  multiparous  patients  non-elastic  through  the 
presence  of  scar  tissue,  the  membranes  should  not  be  rup- 
tured. Eliminative  treatment  should  be  pushed  by  repeated 
intestinal  irrigation,  the  inhalation  of  oxygen  employed  and 
the  circulation  and  the  nervous  system  sustained  and  con- 
trolled by  digitalin  and  codein  hypodermatically.  Small  doses 
of  strychnia  may  be  used  if  necessary.  If  improvement  does 
not  follow  and  uterine  contractions  irritate  the  patient  and 
encourage  convulsions,  the  patient  should  be  promptly  de- 
livered by  Cesarean  section,  abdominal  or  vaginal.  The 
choice  of  operation  will  depend  upon  the  experience  and 
individual  preference  of  the  operator  and  the  condition  of 
the  genital  tract.  If  extensive  incision  should  be  required 
and  the  lower  uterine  segment  is  excessively  distended  or  is 
badly  developed,  abdominal  section  is  unquestionably  safer. 
Before  viability,  vaginal  section;  after  viability,  abdominal 
section  are  indicated. 

The  Treatment  After  Delivery. — No  greater  mistake  can 
be  made  than  to  imagine  that  the  patient  is  safe  and  requir- 
ing no  attention,  because  delivery  has  been  effected.  The 
same  treatment  which  was  carried  out  before  delivery  should 
be  continued,  varying  the  intervals  for  treatment,  and  the 
dosage  of  digitalin,  codein  and  strychnia,  in  accordance 
with  the  conditions  which  develop.  So  long  as  the  patient's 


116  MANUAL   OF    OBSTETRICS 

general  condition  remains  good,  convulsions  of  moderate 
severity  do  not  necessarily  indicate  a  fatal  issue.  If  the 
patient  be  highly  excitable  and  restless,  the  use  of  a  deten- 
tion sheet  will  greatly  assist  in  controlling  her.  If  improve- 
ment occurs  she  will  become  partly  or  wholly  conscious,  will 
be  able  to  swallow  liquids,  the  secretion  of  urine  will  increase, 
the  heart  action  grow  better,  and  the  nervous  disturbance 
gradually  subside. 

Unusual  Methods  of  Treatment. — Edebohls  advised  and 
practised  in  the  toxemia  of  later  pregnancy  the  decapsula- 
tion of  the  kidneys.  This  is  effected  by  exposing  the  kidney 
through  the  usual  lumbar  incision,  incising  its  convex  bor- 
der, and  stripping  back  and  freely  loosening  its  capsule.  In 
some  cases  this  is  followed  by  almost  immediate  increase  in 
the  quantity  of  urine  secreted,  with  improvement  in  the 
patient's  general  condition. 

Sellheim  has  practised  amputation  of  one  or  both  breasts 
in  the  acute  toxemia  of  pregnancy,  usually  with  convulsions. 
In  some  desperate  cases  which  resisted  all  other  treatment, 
this  has  been  successful.  The  operation  is  based  upon  the 
fact  that  in  cows  a  condition  similar  to  acute  toxemia  de- 
velops, which  is  promptly  relieved  by  injecting  air  through 
the  teats  into  the  udder.  In  these  cases  milk  has  not  been 
secreted  normally  and  the  alteration  in  the  tension  of  the 
udder  following  the  injection  of  air  or  sterile  water  usually 
produces  the  secretion  of  milk  with  the  subsidence  of  symp- 
toms. 

The  Specific  Treatment  of  Toxemia. — In  some  cases  with 
sufficient  pulse  tension  and  sluggish  metabolism  the  adminis- 
tration of  thyroid  extract  benefits  toxemic  patients.  In  these 
cases  hypo-thyroidism  has  been  present.  Goitre  of  moderate 
development  is  often  observed  among  these  patients.  In 
cases  of  hyper-thyroidism  with  enlarged  and  active  thyroid, 
the  injection  of  thyroid  extract  is  contraindicated  and  may  be 
followed  by  intense  palpitation  of  the  heart  and  great  dyspnea. 

FETAL  TOXEMIA  IN  LATER  PREGNANCY 

The  fetus  shares  in  the  pathology  and  the  dangers  of  the 
mother  in  the  toxemia  of  later  pregnancy.  Toxins  pass  from 
mother  to  child,  and  from  child  to  mother  through  the  me- 


FETAL  TOXEMIA  IN  LATER  PREGNANCY        117 

diuin  of  the  placenta.  As  this  important  organ  becomes  over- 
burdened, hemorrhage  occurs  in  its  substance,  which  obliter- 
ates considerable  areas,  destroying  their  oxygenating  func- 
tion. In  albuminuric  cases  infarct  occurs  in  varying  degree. 
The  fact  that  the  fetus  undergoes  a  similar  process  with  the 
mother  should  be  remembered  in  the  treatment  of  the  mother. 
It  would  be  obviously  unfair  to  subject  her  to  greatly  in- 
creased risk  to  save  the  life  of  the  fetus  born  diseased.  Dur- 
ing acute  toxemia  the  fetus  may  die  in  the  uterus  from  as- 
phyxia or  visceral  changes.  This  is  often  followed  by  an 
improvement  in  the  mother's  condition  and  by  the  subse- 
quent expulsion  of  the  dead  fetus. 

Should  the  mother  die  in  acute  toxemia  and  fetal  heart 
sounds  be  heard,  the  child  being  viable,  it  is  the  duty  of  any 
physician  present  to  immediately  extract  the  child  from  the 
body  of  the  mother  by  post-mortem  section.  If  the  mother's 
toxemia  has  been  of  brief  duration  the  life  of  the  child  may 
be  saved.  In  many  cases  the  child  subsequently  dies  from 
acute  toxemia. 

The  Treatment  of  Fetal  Toxemia. — Where  the  child  sur- 
vives its  birth  it  requires  especial  attention.  The  bowels 
should  be  irrigated  and  equal  parts  of  boiled  water  and  salt 
solution  should  be  giyen  by  the  bowel  at  regular  intervals 
for  absorption.  The  skin  should  be  thoroughly  cleansed 
and  the  child  wrapped  warmly  in  blankets.  If  the  weather 
is  cold  it  should  be  kept  in  an  incubator  or  in  a  heated  basket 
until  its  nutrition  is  fully  established.  Minute  doses  of 
calomel,  Tffgr.  with  sugar  of  milk,  should  be  given  to  stimulate 
the  action  of  the  liver,  kidneys  and  bowels.  As  the  child 
should  not  nurse  the  mother,  it  may  be  fed  with  albumen 
water  and  peptonized  milk,  well  diluted.  The  intestinal 
tract  should  be  irrigated  once  or  twice  in  twenty-four  hours 
and  the  fluid  left  for  absorption.  Care  must  be  taken  that, 
although  the  child  is  kept  warm,  it  has  abundant  fresh  air, 
and  the  inhalation  of  oxygen  by  a  suitable  mask  will  be  found 
of  advantage.  If  it  survives,  and  a  suitable  wet  nurse  can 
be  found  for  a  short  time,  this  will  greatly  improve  its  chances 
of  life.  Should  the  mother's  toxemic  condition  improve  and 
she  recover  ultimately,  care  must  be  taken  to  encourage  the 
secretion  of  milk.  The  breasts  should  be  gently  massaged 


118  MANUAL   OF   OBSTETRICS 

and  pumped  at  regular  intervals,  and  upon  her  recovery  the 
child  should  be  put  to  the  breast.  If  successful  nursing  can 
be  established  it  will  be  of  great  benefit  to  mother  and  child. 

If  the  child  does  not  do  well,  the  skin  will  remain  dry, 
the  urine  will  be  very  scanty,  yellowish  brick-red,  and  irri- 
tating, there  will  be  dark-greenish  discharges  from  the  bowels, 
the  child  will  rapidly  lose  weight,  it  will  refuse  nourishment 
and  sometimes  water,  and  will  survive  its  birth  but  a  short 
time.  Before  death  the  temperature  may  rise  to  a  high 
point  and  the  child  may  have  typical  convulsions. 

The  Differential  Diagnosis  of  Toxemia  in  the  Later 
Months. — Epilepsy  in  a  pregnant  patient  may  simulate 
toxemia  with  convulsions.  While  the  convulsions  them- 
selves cannot  always  be  differentiated  the  examination  of  the 
blood,  the  heart  and  the  urine,  should  clear  up  the  diagnosis; 
the  'gradual  subsidence  of  the  epileptic  convulsions  and 
the  improvement  of  the  patient  establishes  the  diagnosis. 

Hysterical  patients  in  labor,  or  approaching  labor,  may 
counterfeit  the  convulsions  of  eclampsia.  While  the  seizure 
itself  may  be  typical,  it  will  be  observed  that  these  patients 
have  no  convulsions  without  an  audience.  If  left  entirely 
alone  in  a  quiet  room  the  convulsions  cease.  Under  observa- 
tion they  may  recur. 

In  hystero-maniacal  patients,  convulsive  seizures  may 
simulate  eclampsia.  In  these  cases  a  history  of  previous  hys- 
teria may  often  be  obtained,  the  patient  becomes  conscious 
between  the  attacks,  and  the  examination  of  the  blood  and 
urine  should  clear  up  the  diagnosis. 

Among  the  insane  the  advent  of  labor  pains  may  be  fol- 
lowed by  active  maniacal  convulsions;  in  rare  cases  of  cere- 
bral tumor  in  a  pregnant  woman  at  term  labor  has  produced 
convulsions  which  were  diagnosticated  as  toxemic  and 
eclamptic. 

The  Recovery  of  the  Toxemic  Patient. — The  patient  who 
survives  acute  toxemia  and  the  delivery  of  her  child  may 
have  an  uninterrupted  or  a  prolonged  and  complicated  re- 
covery. In  the  latter,  mental  disturbance  is  a  common ' 
feature.  The  patient  may  not  become  fully  conscious  after 
delivery  and  in  several  days  this  may  be  superseded  by  mel- 
ancholia, and  this  in  turn  by  acute  mania.  It  is  often  neces- 


INFECTIOUS   DISEASES   COMPLICATING   PREGNANCY      119 

sary  to  remove  these  patients  to  a  hospital  for  the  insane, 
where  suitable  appliances  for  restraint,  and  if  necessary 
artificial  feeding,  are  available. 

The  diagnosis  in  these  cases  for  the  life  and  the  recovery  of 
reason,  depends  upon  the  patient's  heredity  and  the  degree 
of  virulence  in  the  toxemic  process.  A  patient  with  an 
acute  insanity  will  escape  death  from  toxemia  and  eclamptic 
convulsions,  only  to  become  chronically  and  hopelessly 
clouded  in  mind.  If  there  is  no  heredity  of  mental  disease 
and  the  patient  be  young  and  previously  healthy,  the  prog- 
nosis for  ultimate  recovery,  both  in  mind  and  body,  is  good. 

During  mental  disturbance  the  patient  should  be  isolated, 
the  process  of  elimination  stimulated,  and  so  soon  as  possible 
nutrition  pushed  in  every  reasonable  way.  Such  patients 
frequently  have  an  extraordinary  aversion  to  the  child,  and 
the  child  should  not  be  with  them.  Cases  have  been  known 
where  a  mother  has  seriously  injured  or  destroyed  the  infant. 

It  cannot  be  too  strongly  urged  that  the  severe  toxemia 
of  pregnancy,  with  or  without  convulsions,  demands  hos- 
pital care. 

INFECTIOUS  DISEASES  COMPLICATING  PREGNANCY. 
THE  MOTHER 

In  some  cases  it  seems  that  pregnancy  tends  to  protect  the 
mother  against  acute  infection;  thus  a  woman  having  several 
children  may  have  one  or  two  of  her  family  ill  with  an  acute 
infectious  disease,  and  she  in  the  pregnant  condition  may  es- 
cape. This  can  only  be  explained  by  the  increased  percent- 
age of  immunizing  substances  found  in  the  blood  of  the 
healthy  patient.  In  other  cases  the  mother  yields  to  infec- 
tion like  other  patients. 

Typhoid. — Pregnant  women  often  become  infected  with 
typhoid  during  the  later  months  of  gestation,  the  infection 
remaining  latent  until  labor  comes  on,  and  during  the  puer- 
peral period  the  temperature  rises  and  the  disease  runs  its 
typical  course.  In  these  cases  diagnosis  may  be  difficult,  as 
it  may  be  that  the  patient  has  a  puerperal  septic  infection. 
A  correct  diagnosis  is  obtained  by  the  Widal  test  and  by  ex- 
cluding the  signs,  symptoms  and  lesions  of  puerperal  sepsis. 
During  pregnancy  typhoid  attacking  a  pregnant  patient  may 


120  MANUAL   OF   OBSTETRICS 

run  a  typical  course.  Abortion  will  not  occur  unless  the 
temperature  is  persistently  high,  when  pregnancy  is  usually 
interrupted. 

Should  this  not  occur,  and  the  patient  go  to  term,  the  fetus 
may  be  permanently  injured,  and  the  child  may  show  the 
results  of  injury  to  the  nervous  system.  In  cases  where 
the  temperature  is  not  high  the  child  may  show  no  ill-effects 
from  the  infection.  There  is  reason  to  believe  that  typhoid 
bacilli  pass  through  the  placenta  and  that  the  fetus  shares 
the  infection  of  the  mother. 

Treatment.- — Typhoid,  like  other  infections,  should  be  con- 
sidered a  complication  of  pregnancy,  and  not  pregnancy  a 
complication  of  typhoid.  Under  no  circumstances  should 
abortion  be  induced,  but  the  mother  should  be  treated  as  if 
not  pregnant.  Such  will  give  the  best  chance  for  mother 
and  child. 

The  mortality  of  typhoid  complicating  pregnancy  depends 
upon  the  severity  of  the  infection  and  the  resisting  power  of 
the  patient.  The  majority  of  cases  recover  without  the  in- 
terruption of  pregnancy  and  without  serious  complications. 

Pneumonia. — Pneumococcus  pulmonary  infection,  croup- 
ous  pneumonia,  may  run  its  typical  course  in  pregnancy. 
The  pneumococcus  is  occasionally  found  with  other  bacteria 
in  septic  cases,  and  the  clinical  picture  is  complex,  the  septic 
element  predominating.  The  diagnosis  and  treatment  of 
pneumococcus  pulmonary  infection  of  pregnancy  is  identical 
with  that  in  the  non-pregnant. 

Catarrhal  pneumonia,  capillary  bronchitis,  may  be  a 
dangerous  complication  of  pregnancy.  The  distention  of  the 
abdomen  by  the  uterus  and  its  contents,  and  the  consequent 
labored  respiration,  tend  to  produce  congestion  of  the  lungs. 
This  would  complicate  catarrhal  pneumonia  and  interfere 
with  the  oxygenation  of  the  patient's  blood.  The  fetus 
shares  the  mother's  disease,  and  may  even  survive  her,  as  in 
a  case  under  the  writer's  observation  where  the  mother,  at- 
tacked by  catarrhal  pneumonia,  came  into  labor,  giving  birth 
to  a  living  child  and  dying  soon  afterward.  The  child  passed 
through  a  characteristic  course  of  the  disease  and  recovered. 

The  diagnosis  of  catarrhal  pneumonia  complicating  preg- 
nancy is  made  by  the  usual  physical  signs  and  symptoms  and 


INFECTIOUS    DISEASES   COMPLICATING    PREGNANCY       121 

the  treatment  is  that  of  the  non-pregnant,  especial  care 
being  necessary  to  support  the  burdened  circulation. 

Cerebro-spinal  Meningitis. — This  dangerous  disease  when 
complicating  pregnancy  usually  brings  on  labor  or  abortion. 
Its  mortality  is  high,  and  the  diagnosis  may  be  confused  by 
petechial  eruptions  which  often  occur  in  puerperal  sepsis. 
Thus  cerebro-spinal  meningitis  may  be  mistaken  for  sepsis 
because  of  high  fever  and  eruption,  and  on  the  contrary,  in 
the  presence  of  an  epidemic  of  meningitis,  a  patient  with 
puerperal  sepsis  may  be  thought  to  have  meningitis. 

The  differential  diagnosis  may  be  aided  in  some  of  these 
cases  by  the  clinical  test  of  anti-meningitic  serum. 

The  Acute  Eruptive  Diseases. — The  exanthemata  when 
complicating  pregnancy  produce  their  characteristic  lesions 
and  symptoms  in  the  mother  and  in  the  fetus  as  well.  Chil- 
dren have  been  born  with  the  characteristic  eruption  of  measles, 
scarlatina,  variola  or  varicella.  As  a  rule,  the  exanthemata 
are  severe  in  the  pregnant  woman.  The  control  of  tem- 
perature is  an  important  part  of  the  treatment  and  every 
means  should  be  taken  to  favor  the  early  and  complete  ap- 
pearance of  the  eruption.  Such  a  course  will  best  conserve 
the  interests  of  mother  and  fetus  as  well.  Prolonged  high 
temperature,  with  delayed  eruption,  usually  brings  on  abor- 
tion or  premature  labor. 

Vaccination. — The  question  is  frequently  raised  whether 
vaccination  against  variola  should  be  practised  on  pregnant 
patients.  During  the  times  when  small-pox  was  present  in 
the  city  the  writer  has  repeatedly  vaccinated  patients  at  vari- 
ous periods  of  pregnancy  with  uniformly  good  results.  There 
has  been  no  extreme  reaction,  and  in  no  case  has  pregnancy 
been  disturbed.  It  is  evident  that  the  fetus  must  be  pro- 
tected by  the  vaccination,  but  for  how  long  a  time  after  birth 
it  is  difficult  to  estimate.  If  vaccination  protects  the  mother 
for  several  years  it  should  certainly  protect  the  fetus  for  at 
least  one  year. 

In  general,  it  may  be  said  that  pregnancy  is  no  contra- 
indication to  the  use  of  vaccines  and  antitoxins.  On  the  con- 
trary, the  prompt  control  of  infection  by  such  means  will 
tend  to  prevent  abortion  and  allow  pregnancy  to  go  on  to 
its  natural  termination. 


122  MANUAL   OF   OBSTETRICS 

Diphtheria. — Infection  by  the  bacillus  of  diphtheria  alone, 
without  mixed  infection,  is  susceptible  to  control  by  anti- 
toxin, and  is  not  a  serious  complication  of  pregnancy.  The 
characteristic  lesions  may  be  found  in  the  mucous  mem- 
brane of  the  vagina,  as  well  as  in  the  throat.  In  the  observa- 
tion of  the  writer,  a  patient  recovered  from  such  diphtheria 
without  the  development  of  septic  infection  and  without  the 
interruption  of  pregnancy. 

The  diagnosis  is  made  by  bacterial  culture  and  the  prompt 
and  thorough  use  of  antitoxin  is  indicated. 

Influenza. — One  of  the  most  dangerous  diseases  attacking 
pregnant  patients  is  influenza.  This  arises  from  its  ten- 
dency to  produce  catarrhal  pneumonia  and  appendicitis,  each 
of  which  is  serious  in  pregnancy.  Danger  arises  because 
mild  cases  of  influenza  are  frequently  neglected.  The  preg- 
nant patient  may  not  receive  adequate  treatment  until  she 
becomes  seriously  ill.  Influenza  is  always  a  serious  compli- 
cation of  pregnancy,  and  a  mild  attack  should  be  treated  by 
absolute  rest  in  bed,  with  disinfection  of  the  fauces  and  nares, 
and  the  use  of  suitable  tonics.  A  laryngologist  should  be 
summoned  in  these  cases  and  the  nose  and  throat  thoroughly 
inspected  and  disinfected.  It  may  be  necessary  to  repeat 
such  disinfection  for  several  days. 

The  Infection  of  the  Bacillus  Coli  Communis. — This  is  one 
of  the  most  common  and  often  serious  complications  of  preg- 
nancy. The  germ  may  attack  the  gall  bladder,  one  or  both 
kidneys,  or  the  appendix  and  large  intestine.  It  may  gain 
access  to  the  body  through  infected  fluids,  or  may  enter  the 
blood  through  capillaries  which  are  near  impacted  feces. 

All  forms  of  this  infection  are  characterized  by  high  leuko- 
cytosis,  comparatively  high  temperature,  and  in  severe  cases 
by  frequent  rigors.  If  the  patient  receives  no  specific  treat- 
ment the  disease  may  run  a  favorable  course,  being  severe 
in  accordance  with  the  focus  of  infection,  and  if  the  temper- 
ature be  persistently  high  the  fetal  life  will  be  lost.  Fatal 
results  occur  from  exhaustion  and  from  the  development  of 
mixed  infection,  with  streptococci  and  staphylococci. 

Cholecystitis. — Many  pregnant  patients  suffer  from  some 
degree  of  infection  of  the  gall  bladder  during  gestation.  The 
symptoms  are  tenderness  over  the  gall  bladder,  diffuse  pain 


INFECTIOUS   DISEASES   COMPLICATING   PREGNANCY      123 

in  the  right  hypochondrium,  often  felt  beneath  the  scapula, 
a  furred  and  coated  tongue,  vomiting,  often  slight  jaundice, 
moderately  elevated  pulse  and  temperature,  leukocytosis, 
and  the  general  symptoms  accompanying  an  acute  infection. 

The  prognosis  depends  upon  the  severity  of  the  infection 
and  when  it  becomes  mixed  a  severe  hepatic  and  septic  in- 
fection may  result. 

Treatment. — Rest  in  bed,  the  free  use  of  gentle  laxatives, 
liquid  diet,  and  lavage  of  the  intestines,  with  the  application 
of  dry  cold  over  the  region  of  the  gall  bladder.  In  severe 
cases,  with  the  patient  in  good  general  condition,  the  gall 
bladder  should  be  incised  and  drained. 

The  Pyelitis  of  Pregnancy.— By  this  name  is  designated  the 
infection  of  one  or  both  kidneys  by  the  bacillus  coli  com- 
munis.  Usually  the  pelvis  of  the  kidney  is  the  site  of  the  in- 
fection, in  severe  cases  the  kidney  substance  becoming 
thoroughly  riddled.  The  mode  of  infection  is  through  the 
urethra,  bladder  and  ureters,  through  the  blood  stream,  or 
from  the  presence  of  the  over-distended  right  colon.  The 
right  kidney  is  most  often  affected,  less  frequently  the  left, 
and  both  kidneys  comparatively  rarely. 

The  differential  diagnosis  is  made  by  the  high  leukocytosis, 
20,000  to  25,000,  and  the  persistent  acid  reaction  of  the  urine 
which  swarms  with  the  bacillus  coli  communis.  This  germ 
does  not  decompose  urea,  and  hence  the  urine  remains  acid. 
It  does  not  also  form  an  antitoxin. 

The  treatment  of  this  condition  consists  in  absolute  rest 
in  bed,  lavage  of  the  intestine,  a  milk  and  water  diet,  with 
the  free  use  of  urotropin  or  some  other  mild  antiseptic  of  the 
urinary  tract.  Should  the  disease  not  yield  to  these  meas- 
ures local  treatment  may  be  instituted  by  catheterizing  the 
ureters  and  irrigating  the  pelvis  of  the  kidney  with  boric 
acid  solution  or  salt  solution. 

Where  the  infection  is  limited  to  the  right  kidney  it  will 
cause  characteristic  pain  in  this  region,  and  in  thin  women 
the  kidney  may  become  so  large  as  to  be  recognized  by  pal- 
pation. 

When  medicinal  and  local  treatment  fail  and  the  patient 
ceases  to  improve,  or  grows  worse,  the  writer  has  had  good 
results  by  exposing  the  right  kidney  through  the  usual  lum- 


124  MANUAL    OF    OBSTETRICS 

bar  incision.  At  each  extremity  a  stitch  of  good-sized 
chromic  catgut  is  passed  through  the  inner  layers  of  the 
wound  and  through  the  capsule  of  the  kidney,  and  these 
stitches  are  tied.  This  practically  secures  the  kidney  in  the 
wound,  with  its  convex  surface  in  the  incision.  This  surface 
is  then  incised  and  the  gloved  finger  passed  through  the  kid- 
ney substance  to  the  pelvis.  A  free  discharge  of  dark  blood 
follows  this  manipulation,  and  in  this  blood  the  bacillus  coli 
communis  has  been  found  abundantly  in  pure  culture.  If 
the  blood  which  exudes  from  the  kidney  is  allowed  to  flow 
freely  over  the  edges  of  the  wound,  infection  may  occur  and 
pus  may  develop.  A  strand  of  gauze  is  passed  through  the 
kidney  substance  to  its  pelvis,  the  extremities  of  the  wound 
are  closed,  and  the  kidney  is  allowed  to  drain  externally. 
The  kidney  wound  is  allowed  to  close  gradually. 

In  the  writer's  experience  this  operation  has  been  success- 
ful, the  patient  recovering  without  the  interruption  of  preg- 
nancy. 

If  both  kidneys  be  involved  it  is  usually  thought  best  to 
avoid  active  interference  and  to  give  the  patient  general 
treatment,  with  irrigation  through  the  ureters. 

Appendicitis. — While  all  appendicitis  during  pregnancy 
is  not  the  result  of  the  bacilli  coli  communis  yet  many  cases 
are.  The  signs  and  symptoms  are  characteristic  of  the  dis- 
ease in  the  non-pregnant.  The  varying  tenderness,  so  com- 
mon during  pregnancy,  must  be  kept  in  mind  in  palpating 
the  abdomen  to  outline  the  inflamed  appendix.  The  pres- 
ence of  leukocytosis,  the  abdominal  symptoms,  and  the 
patient's  altered  pulse  and  temperature,  will  confirm  the 
diagnosis.  In  many  cases  the  kidney  and  appendix  are  in- 
volved in  the  same  patient  at  the  same  time,  and  we  must 
believe  that  in  many  others  the  gall  bladder  is  often  the  site 
of  infection. 

The  removal  of  the  affected  appendix  as  soon  as  a  diagnosis 
can  be  made  is  urgently  necessary.  If  this  be  not  done  the 
infected  appendix  is  a  constant  menace  during  pregnancy, 
and  may  rupture  during  labor,  its  contents  infecting  the  peri- 
toneum. Should  the  appendix  perforate  and  abscess  form, 
one  wall  of  the  abscess  is  usually  made  by  the  wall  of  the 
uterus.  Should  uterine  contractions  bring  on  labor,  this 


INFECTIOUS   DISEASES   COMPLICATING    PREGNANCY       125 

abscess  will  be  ruptured,  its  contents  escaping  into  the  peri- 
toneal cavity.  Hence  in  operating  for  appendicitis  at  full 
term,  it  may  be  thought  necessary  to  first  empty  the  uterus 
by  Cesarean  section  and  then  deal  with  the  appendix  and  its 
abscess.  In  this  way  efficient  drainage  could  be  secured 
after  the  uterus  had  been  reduced  in  size  and  the  danger  of 
rupture  from  the  abscess  wall  had  been  avoided. 

In  these  cases  it  is  rare  that  one  focus  of  infection  only  is 
present.  In  the  writer's  experience  in  pyelitis,  the  appendix 
is  frequently  involved,  as  well  as  in  cholecystitis.  The  ob- 
stetrician must  use  his  judgment  should  cases  come  to  op- 
eration, and  if  appendicitis  be  suspected,  although  it  may 
not  be  possible  to  accurately  diagnosticate  acute  appendicitis, 
the  appendix  should  be  removed.  This  the  writer  has  done 
in  cases  of  pyelitis  treated  by  drainage,  with  uniformly  good 
results. 

Syphilis. — One  of  the  most  important  complications  of 
pregnancy  is  maternal  syphilis.  The  pregnant  woman  seems 
a  good  subject  for  this  disease,  and  unless  promptly  con- 
trolled runs  its  characteristic  course  with  severity  and  rapid- 
ity. The  syphilitic  eruption  may  be  unusually  active  and 
be  mistaken  for  variola.  In  these  cases  fever  is  high  and  the 
patient  usually  suffers  from  a  mixed  infection. 

The  diagnosis  of  syphilis  contracted  during  pregnancy 
is  made  in  the  usual  manner.  The  treatment  consists  in  the 
prompt  use  of  salvarsan,  care  being  taken  to  make  the  dose 
proportionate  to  the  development  and  vigor  of  the  mother. 
In  cases  which  do  badly  with  salvarsan  the  biniodid  of  mer- 
cury has  been  successfully  used,  and  in  the  later  stages  the 
iodides.  The  local  lesions  should  be  persistently  and  thor- 
oughly disinfected  to  avoid  the  development  of  mixed  in- 
fection. Knowing  the  frequent  tendency  of  syphilis  to 
cause  abortion  the  obstetrician  must  treat  these  cases 
promptly  and  thoroughly.  Should  abortion  occur,  mixed 
infection  is  to  be  dreaded  and  avoided.  The  genital  tract 
should  be  disturbed  as  little  as  possible,  and  every  precau- 
tion should,  be  taken  to  secure  the  entire  discharge  of  the 
ovum. 

Gonorrhea. — Infection  of  the  gonococcus  complicating 
pregnancy  may  become  severe  and  dangerous  with  the  de- 


126  MANUAL   OF   OBSTETRICS 

velopment  of  mixed  infection.  The  gonococcus  alone  rarely 
produces  severe  symptoms  or  dangerous  conditions.  Cystitis 
is  a  frequent  development  in  these  cases,  because  the  func- 
tions of  the  bladder  are  disturbed  so  often  by  the  growing 
uterus.  Confusion  in  diagnosis  may  also  happen,  because 
the  patient  may  develop  gonorrheal  rheumatism,  and  this 
may  be  mistaken  for  multiple  septic  infection.  The  vac- 
cines of  gonorrhea  may  be  tried  in  these  cases  and  good 
results  are  reported.  The  usual  treatment  of  absolute  rest 
and  milk  and  water  diet,  the  use  of  laxatives,  and  later  in  the 
disease  local  antisepsis  with  counter-irritants,  will  usually 
be  found  successful. 

Tuberculosis. — The  tubercular  woman  who  becomes  preg- 
nant may  be  apparently  benefited  by  pregnancy.  There 
may  be  increased  appetite,  better  weight  and  color,  and  ap- 
parently the  patient's  power  of  resistance  is  enhanced.  So 
soon,  however,  as  the  pregnancy  is  over  the  tubercular  pro- 
cesses become  more  active  than  before,  and  usually  proceed 
rapidly  to  a  fatal  issue.  This  fact  has  led  to  much  discussion 
concerning  the  propriety  of  terminating  pregnancy  as  soon  as 
possible  in  a  tubercular  patient.  The  majority  of  observers 
believe  that  in  young  primiparse  whose  powers  of  assimilation 
are  good,  and  where  proper  surroundings  can  be  obtained, 
that  it  is  unnecessary  to  interrupt  pregnancy  because  of 
tubercular  infection.  In  multiparse,  and  especially  those 
debilitated  by  repeated  childbirth,  pregnancy  should  be 
promptly  interrupted,  with  the  possible  hope  of  prolonging 
or  saving  the  mother's  life. 

The  usual  treatment  of  tuberculosis  in  the  nonpregnant 
is  indicated  with  pregnant  patients.  Fortunately  the  latter 
often  respond  more  vigorously  than  do  patients  who  are  not 
pregnant. 

THE  FETUS  IN  ACUTE  INFECTIOUS  DISEASES 

The  fetus  shares  in  the  acute  infection  of  the  mother  and 
its  consequences.  It  has  been  repeatedly  observed  that 
bacilli  pass  from  mother  to  child  through  the  placenta. 
Hence  the  fetus  may  have  the  mother's  disease  while  in 
utero,  and  in  cases  where  the  mother's  temperature  is  high, 
and  she  has  rigors,  the  fetal  movements  may  be  unusually 


THE    FETUS    IN   ACUTE   INFECTIOUS   DISEASES  127 

active.  In  acute  malarial  intoxication  the  mother's  chills 
and  fever  may  be  accompanied  by  fetal  movements  so  active 
that  one  must  conclude  that  the  fetus  has  rigors  as  well. 

There  is  no  specific  treatment  which  can  be  used  in  these 
cases  for  the  especial  purpose  of  preserving  the  life  of  the 
child.  So-called  specific  medication  may  be  freely  used  and 
seems  in  many  cases  to  be  successful. 

Syphilis  affects  the  fetus  so  profoundly  that  it  is  the  great- 
est cause  of  fetal  mortality.  Its  lesions  in  the  fetus  are  so 
characteristic  that  they  furnish  a  separate  chapter  in  fetal 
pathology. 

Fetal  Syphilis  of  Paternal  Origin. — Where  the  mother  is 
sound  and  the  fetus  syphilitic,  the  mother  may  escape  in- 
fection through  increased  resistance  on  the  part  of  her  tissues, 
which  causes  the  formation  in  the  uterus  of  thickened  endo- 
metrium;  so  a  patient  having  given  birth  to  a  syphilitic  fetus, 
although  she  may  herself  escape  syphilis,  has  a  chronic  endo- 
metritis. 

The  characteristic  fetal  lesions  are  seen  in  the  viscera  and 
in  the  nervous  system,  the  skin  and  its  appendages.  The 
liver  is  considerably  enlarged,  a  characteristic  eruption  of 
reddish  copper  color  is  found  about  the  anus  and  genital 
organs  and  may  develop  over  the  body;  there  is  chronic  ca- 
tarrh, the  color  of  the  child  is  pale  and  yellow,  and  the  gen- 
eral appearance  that  of  premature  age  and  decay.  The 
epiphyses  of  the  long  bones  show  a  layer  of  yellow  material 
between  the  shaft  and  the  cartilage.  Fetal  death  usually 
occurs  through  changes  in  the  liver  or  in  the  central  nervous 
system. 

Syphilis  is  the  most  frequent  cause  of  abortion.  When 
this  happens  after  the  placenta  has  formed,  areas  of  yellow- 
ish-gray tissue  are  seen  throughout  the  placental  substance. 
The  oxygenating  power  of  the  placenta  is  gradually  lessened 
until  death  of  the  fetus  occurs.  Before  the  placenta  has 
formed  syphilitic  changes  in  the  vessels  of  the  chorion  cause 
hemorrhage  and  the  death  of  the  embryo. 

Where  the  mother  is  syphilitic  and  the  father  sound,  the 
embryo  may  escape  active  syphilis,  especially  if  the  mother 
receives  vigorous  anti-syphilitic  treatment.  When  both 
parents  are  syphilitic  the  death  of  the  embryo  is  the  result. 


128  MANUAL   OF   OBSTETRICS 

Fetal  death  is  followed  by  maceration,  which  may  obscure 
somewhat  the  characteristic  lesions. 

The  treatment  of  syphilis  in  the  embryo  is  the  vigorous 
treatment  of  the  mother.  In  this  it  must  be  remembered 
that  anemia  is  one  of  the  dangerous  conditions  developing 
during  syphilis.  If  drugs  be  given  that  act  vigorously  upon 
the  syphilitic  germ  they  must  not  be  allowed  to  interfere 
with  the  general  nutrition  of  the  patient,  so  the  use  of 
arsenic  and  iron,  with  selected  feeding,  is  indicated.  Where 
the  mother  has  lost  embryos  repeatedly  through  syphilis, 
anti-syphilitic  treatment,  accompanied  by  curetting,  may 
enable  her  to  produce  a  living  child. 

Parasitic  Diseases. — While  we  are  comparatively  familiar 
with  the  pathology  of  malaria,  other  parasitic  diseases  of 
more  recent  discovery  have  not  yet  been  thoroughly  studied. 
The  fetus  shares  the  mother's  malaria,  and  like  her,  benefits 
by  the  use  of  quinine  and  other  drugs.  The  fear  that  quinine 
given  in  these  cases  in  large  doses  may  produce  abortion  is 
unfounded  if  the  patient  be  in  the  active  stages  of  malaria. 

Pernicious  and  severe  malarial  intoxication  may  interrupt 
pregnancy.  In  this,  as  in  other  acute  diseases,  the  general 
rule  must  be  followed,  that  the  mother  must  be  treated  as  if 
she  were  not  pregnant,  and  that  under  no  circumstances 
should  abortion  be  produced. 

CHRONIC  DISEASES,  POISONING,  AND  ACCIDENTS  COMPLI- 
CATING   PREGNANCY.     DISEASES    PRODUCING 
DEGENERATIVE  CHANGES 

Acute  rheumatic  infection  in  mother  and  fetus  may  be 
followed  by  the  development  of  endocarditis  and  permanent 
damage  to  the  heart  and  vessels.  Heart  disease  complicating 
pregnancy  is  serious  in  proportion  to  the  severity  of  the  dis- 
ease and  the  extent  and  location  of  the  lesion.  The  mitral 
valve  is  most  frequently  affected,  causing  mitral  insufficiency 
or  a  mitral  obstructive  lesion.  Aortic  disease  may  also  be 
present,  and  so  may  alterations  in  the  pulmonary  valve. 
Cardiac  lesions  may  be  diagnosticated  in  the  usual  manner  by 
physical  examination.  Murmurs  are  not  of  positive  value, 
for  such  are  not  infrequently  found  during  pregnancy  in 
patients  without  valvular  lesion.  Of  especial  moment  are 


CHRONIC  DISEASES,  ETC.,  COMPLICATING  PREGNANCY    129 

the  size  of  the  heart,  as  made  out  by  percussion,  the  char- 
acter of  its  muscular  action  as  obtained  by  auscultation,  and 
the  presence  or  absence  of  an  interval  between  the  contrac- 
tion of  the  ventricles  and  its  pulse-wave.  From  this  we  may 
learn  whether  compensation  has  been  effected,  whether  it  is 
maintained,  and  whether  the  lesion  is  or  is  not  obstructive. 

The  management  of  heart  disease  complicating  pregnancy 
depends  for  its  success  on  the  general  condition  of  the  mother. 
Realizing  the  added  tax  which  pregnancy  brings  upon  the 
circulation,  all  additional  burden  must  be  avoided.  Abun- 
dant rest,  fresh  air,  the  avoidance  of  strain  and  apprehension, 
are  imperative.  The  patient's  nutrition  and  excretion 
should  receive  careful  attention,  and  drugs  should  not  be 
given  to  influence  the  action  of  the  heart  unless  absolutely 
necessary.  In  proportion  to  the  compensation  present, 
gentle  exercise  is  indicated,  either  active  or  passive.  If 
anemia  be  present,  this  must  be  corrected. 

The  interruption  of  pregnancy  may  become  necessary  in 
heart  disease.  Rapidly  falling  compensation,  beginning 
edema  of  the  lungs,  and  other  portions  of  the  body,  inability 
to  sleep,  dyspnea,  and  prostration,  indicate  that  pregnancy 
must  cease.  If  the  mother  earnestly  desires  the  life  of  the 
child  every  effort  may  be  made  to  prolong  gestation,  until 
viability  is  assured.  When  labor  occurs,  the  additional 
muscular  strain  of  parturition  may  greatly  oppress  the  heart, 
causing  cyanosis,  dyspnea  and  syncope.  To  relieve  the 
patient's  distress  ether  may  be  inhaled  with  oxygen,  and  the 
labor  terminated  as  speedily  as  possible.  Moderate  bleeding 
is  sometimes  useful.  Cardiac  tonics  should  be  given  during 
labor,  and  so  soon  as  the  uterus  is  emptied. 

No  apparent  effect  from  cardiac  disease  of  the  mother 
has  been  observed  with  the  fetus,  but  in  proportion  as  her 
vigor  is  impaired,  the  vigor  and  development  of  the  child  may 
also  be  lessened. 

Heart  lesions  in  the  fetus  are  usually  congenital  and  may 
result  from  failure  of  the  Eustachian  valve  to  close.  This 
produces  partial  asphyxiation  which  may  become  complete 
at  any  time  after  birth.  Such  children  are  partly  cyanosed  in 
color,  with  rapid  feeble  heart  action  and  sluggish  circulation. 
They  require  stimulation  from  birth. 
9 


130  MANUAL    OF   OBSTETRICS 

Degenerative  Disease  of  the  Viscera  Complicating  Preg- 
nancy.— Arterio-sclerosis  antedating  pregnancy  may  become 
aggravated  during  gestation.  This  would  cause  degenera- 
tion of  the  heart  muscle,  increase  in  atheroma  in  the  vessels, 
distention  of  the  walls  of  veins,  the  development  of  varicos- 
ities,  and  multiple  hemorrhages  from  rupture  of  capillaries. 
Chronic  interstitial  nephritis  may  develop,  and  if  toxemia 
be  added  the  condition  may  culminate  in  eclampsia. 

Pregnancy  is  dangerous  with  these  patients  and  strict 
attention  must  be  paid  to  hygiene  if  pregnancy  is  to  safely 
continue.  In  severe  cases  abortion  occurs  from  hemorrhage 
in  the  ovum,  with  degenerative  changes  in  the  vessels  of  the 
chorion  or  placenta. 

Acute  Degenerative  Disease. — Probably  from  septic  in- 
fection the  maternal  liver  during  pregnancy  may  undergo 
an  acute  degenerative  process,  known  as  acute  yellow  atrophy. 
This  is  usually  accompanied  by  high  fever  and  symptoms  of 
severe  septic  intoxication.  There  is  intense  jaundice  and 
mental  disturbance,  and  sometimes  delirium.  The  exact 
cause  of  the  lesion  is  not  clearly  known,  but  the  symptoms 
point  to  acute  infection.  The  disease  is  fatal  and  treatment 
beyond  palliation  is  unavailing. 

Acute  Degenerative  Processes  in  the  Fetus. — The  fetus 
shares  with  the  mother  in  lesions  in  the  vessels  of  the  viscera, 
produced  by  acute  degenerative  disease.  In  atrophy  of  the 
liver  the  placenta  is  bile-stained,  the  child  is  jaundiced,  and 
hi  its  organs  shows  changes  corresponding  with  those  in  the 
mother. 

The  success  of  salvarsan  in  syphilis  has  led  to  the  hope  that 
it  may  also  be  useful  in  other  forms  of  infection.  It  has  been 
found  efficient  in  some  parasitic  disorders  which  produce 
rapid  disintegration  of  the  blood  and  degenerative  changes  in 
the  viscera.  It  would  seem  rational  to  hope  that  it  may  be 
as  efficient  in  correcting  diseased  conditions  in  the  fetus  as 
in  the  mother. 

The  Influence  of  Maternal  and  Paternal  Infection  Upon 
the  Offspring. — This  important  question  often  comes  to  the 
attention  of  the  observer,  and  usually  in  relation  to  syphilis. 
While  those  who  treat  syphilis  are  sanguine  as  to  the  possi- 
bility of  complete  cure  and  the  production  of  healthy  off- 


EFFECT   OF   POISONS   UPON   MOTHER  AND   CHILD         131 

spring  by  those  who  have  been  syphilitic,  the  obstetrician 
sees  many  cases  in  which  this  hope  ends  in  disappointment. 
In  syphilis  not  only  must  persistent  treatment  be  employed, 
but  abundant  time  must  elapse  for  the  development  of  sec- 
ondary and  tertiary  symptoms,  and  their  absence  must  be 
proven  before  it  can  be  hoped  that  syphilis  has  been  cured. 
It  is,  however,  possible,  where  the  syphilis  is  maternal,  and 
the  father  is  sound,  to  so  improve  the  condition  of  the  mother 
by  active  treatment  that  she  may  give  birth  to  a  non-specific 
comparatively  vigorous  offspring.  In  common  with  other 
diseases,  pregnancy  is  often  a  great  stimulus  to  diseased 
processes  when  it  occurs  after  the  original  infection,  so  in 
tuberculosis  and  syphilis  if  pregnancy  is  added  to  the  original 
disease  pathological  conditions  will  develop  with  increased 
vigor  and  rapidity.  Increased  knowledge  of  infectious  and 
parasitic  diseases  should  explain  many  hitherto  unknown 
causes  of  abortion  and  should  tend  to  diminish  this  complica- 
tion of  pregnancy. 

THE  EFFECT  OF  POISONS  UPON  MOTHER  AND  CHILD 

Pregnant  women  are  exposed  to  poisons  in  occupations  in 
which  poisonous  chemicals  are  used,  by  accidentally  taking 
poisons  and  occasionally  through  suicide. 

Arsenic,  lead,  and  poisons  which  give  off  irritant  fumes, 
such  as  nitric  acid,  seriously  injure  the  mother  and  the  fetus 
as  well.  The  absorption  of  arsenic  produces  irritation  of 
the  intestine  and  kidney,  and  disorders  of  the  skin  and  ner- 
vous system. 

The  fetus  shares  with  the  mother  in  this  complication  and 
if  violent  vomiting  and  purging  ensue  abortion  usually  oc- 
curs. Lead  produces  obstinate  constipation,  palsy  and  fre- 
quently causes  the  death  of  the  fetus.  Irritant  fumes  cause 
chronic  bronchitis,  preventing  oxygenation  of  the  blood,  and 
violent  coughing  often  produces  abortion.  Mercury  pro- 
duces salivation,  diarrhea,  nephritis  and,  where  the  poisoning 
is  long-continued,  dysentery  and  abortion. 

Among  those  poisons  which  act  more  slowly  and  affect 
the  nervous  system  profoundly,  is  tobacco.  Pregnant  women 
working  in  tobacco  factories  suffer  from  nausea  and  vomiting, 


132  MANUAL   OF   OBSTETRICS 

paresis  and  abortion.  If  they  go  to  term  the  amniotic  liquid 
is  discolored,  and  there  are  evidences  that  absorption  from 
tobacco  interferes  with  the  development  of  the  child. 

Alcohol,  except  in  the  smallest  quantities,  is  a  direct  poison 
to  the  fetus  if  taken  by  the  mother.  There  is  abundant 
evidence  to  show  that  it  seriously  interferes  with  the  growth 
and  development  of  the  fetus  and  that  its  effects  are  especially 
disturbing  upon  the  nervous  system.  Unfortunately,  abor- 
tion is  less  common  than  with  more  irritant  poisons,  but 
rarely  happens  unless  the  mother  has  delirium  tremens,  or 
receives  mechanical  injury  while  intoxicated.  Opium  and 
other  narcotic  substances  interfere  with  fetal  growth  and  de- 
velopment. 

Direct  violence,  caused  by  the  rapid  and  jarring  motion 
of  machinery,  is  a  frequent  cause  of  abortion  among  pregnant 
women  working  in  factories.  This  is  especially  frequent 
where  machinery  must  be  controlled  by  the  feet,  or  where 
the  foot  treadle  is  used. 

In  cases  of  attempted  suicide,  if  irritant  poisons,  like  ar- 
senic, be  taken  and  the  mother  vomits  and  purges  violently, 
should  she  survive  the  poison,  abortion  is  apt  to  occur  through 
mechanical  separation  of  the  ovum.  Where  carbolic  acid  is 
taken  the  rapid  and  deadly  action  of  this  substance  upon  the 
blood  of  the  mother  produces  asphyxiation  in  the  fetus.  If 
narcotics  be  used,  the  child  also  dies  from  gradually  develop- 
ing asphyxia. 

Poisoning  during  pregnancy  should  be  treated  as  in  the 
non-pregnant.  Suffering  should  be  promptly  allayed  with 
opium,  given  hypodermatically,  and  this  will  have  the  further 
purpose  of  preventing  abortion,  if  possible.  If  a  viable  child 
is  born  from  a  poisoned  mother,  efforts  should  be  made  to 
sustain  its  circulation  and  to  secure  the  elimination  of  the 
poison.  Artificial  warmth  and  the  use  of  oxygen  by  the  pul- 
motor  are  indicated. 

ACCIDENTS 

Pregnant  women,  if  healthy,  often  survive  severe  accidents 
without  abortion.  This  fortunate  result  depends  greatly 
upon  prompt  and  efficient  treatment  following  the  accident. 
If  shock  be  combated,  and  anesthesia  be  skilfully  produced 


ABNORMAL    CONDITIONS    OF    PELVIC    ORGANS  133 

during  operation,  the  patient  may  be  carried  through  her 
recovery  without  abortion.  To  secure  this  result,  pain  and 
restlessness  must  be  prevented  as  completely  as  possible. 
Pregnant  women,  if  healthy,  bear  mechanical  injury  and  hem- 
orrhage comparatively  well.  The  interruption  of  pregnancy 
depends  much  upon  the  nature  of  the  accident.  Should  the 
abdominal  and  pelvic  regions  be  the  site  of  injury  abortion 
is  almost  inevitable.  Other  portions  of  the  body  may  be 
severely  injured,  and  still  the  fetus  escape.  In  gunshot  and 
stab-wounds  of  the  abdomen  the  fetus  may  be  wounded 
or  killed  by  the  original  injury  to  the  mother. 

In  the  later  months  of  pregnancy  mechanical  violence  is  es- 
pecially dangerous  to  the  fetus  through  separation  of  the 
placenta.  Thus  a  pregnant  woman  thrown  from  a  car  or 
carriage  or  falling  a  considerable  distance  may  not  receive 
severe  or  fatal  injury,  but  placental  separation  may  expose 
her  to  the  dangers  of  hemorrhage  and  septic  infection,  and 
may  cause  the  death  of  the  child.  In  this,  as  in  other  cases 
of  accident,  the  patient  must  be  put  to  rest  at  once,  opium 
given  to  secure  quiet,  and  such  stimulation  as  may  be  neces- 
sary. Should  a  surgical  operation  be  performed  anesthesia 
should  be  as  brief  as  possible,  pain  and  restlessness  are  to  be 
feared  after  operation,  and  the  patient  should  be  controlled 
after  the  anesthesia  by  opium. 

In  accidents  which  prove  rapidly  fatal  to  the  mother,  if 
the  child  be  viable,  and  heart  sounds  be  heard,  the  fetus 
should  be  immediately  extracted  from  the  body  of  the  mother 
by  Cesarean  section. 

ABNORMAL  CONDITIONS  OF  THE  PELVIC  ORGANS  COMPLI- 
CATING PREGNANCY 

If  pregnancy  be  complicated  by  disease  of  the  pelvic  vis- 
cera, the  mother  is  exposed  to  additional  danger  and  the  life 
of  the  fetus  is  also  at  stake.  Where  the  mother  has  had  in- 
flammation in  the  abdomen,  and  the  uterus,  tubes  and  ovaries 
are  adherent  to  the  intestine,  the  natural  development  of  the 
uterus  may  be  prevented,  the  mother  will  suffer  pain  from 
stretching,  and  traction  upon  adhesions,  and  abortion  may 
be  threatened.  Infection  of  the  intestines,  whether  appen- 
dicitis or  colitis,  is  peculiarly  severe  because  of  the  mechanical 


134  MANUAL   OF   OBSTETRICS 

stasis  in  the  abdomen  and  is  very  apt  to  cause  abortion. 
Chronic  appendicitis  or  colitis  is  frequently  lighted  up  and 
made  acute  by  pregnancy. 

Where  pregnancy  occurs  in  a  patient  who  has  suffered 
from  salpingitis  with  adhesions,  interference  with  the  de- 
velopment of  the  uterus,  pain  and  possibly  the  rekindling  of 
inflammation,  may  ensue.  Should  severe  disturbance  be 


Fig.  35. — Pregnancy  complicated  by  ovarian  tumor. 

caused  abortion  may  result.  Where  this  complication  de- 
velops the  mother  must  be  put  at  once  at  rest,  sedatives  given 
to  control  pain,  the  intestinal  canal  kept  empty,  and  the 
patient's  strength  and  nutrition  supported.  The  use  of 
heat  or  cold  upon  the  abdomen  is  attended  with  some  risk, 
and  caution  must  be  exercised.  Where  the  patient  does  not 
grow  better  with  such  treatment,  if  indications  for  operation 
arise  such  should  be  undertaken. 


ABNORMAL    CONDITIONS    OF    PELVIC    ORGANS  135 

Pelvic  tumors  complicating  pregnancy,  if  ovarian,  are 
dangerous  to  the  mother  because  of  their  tendency  to  twist 
the  pedicle.  For  this  reason  an  ovarian  tumor  should  be  re- 
moved so  soon  as  discovered.  Rapidly  growing  ovarian 
cysts  may  lead  to  error  in  diagnosis  and  may  be  mistaken 
for  pregnancy  with  polyhydramnios;  so  also  may  poly- 
hydramnios  be  confused  with  ovarian  cyst. 

One  of  the  most  frequent  abnormal  conditions  of  the  uterus 
complicating  pregnancy  is  the  presence  of  fibroid  growths. 
If  such  be  submucous  and  attached  at  the  lower  uterine  seg- 
ment, it  may  form  an  obstacle  to  labor.  During  labor  the 
tumor  may  be  retracted  and  the  head  forced  below  it,  or  the 
tumor  may  present  in  front  of  the  head,  or  head  and  tumor 
may  become  impacted  in  the  pelvis. 

Interstitial  fibroid  growths  may  so  weaken  the  uterine 
muscle  that  labor  does  not  develop  normally.  The  diagnosis 
of  this  condition  may  be  difficult  during  pregnancy,  as  no 
tumor  is  felt  by  palpation.  Such  patients  usually  require 
section  for  delivery,  when  the  character  of  the  tumor  will  be- 
come apparent.  Should  no  sound  uterine  tissue  be  found  at 
the  site  of  incision  the  operation  must  be  terminated  by  hys- 
terectomy. Sub-peritoneal  fibroids  rarely  complicate  preg- 
nancy unless  they  become  of  excessive  size.  Fibroid  tumors 
of  the  uterus  share  in  uterine  involution  after  the  birth  of  the 
child.  Small  tumors  usually  disappear,  in  some  cases  enu- 
cleated fibroids  become  polyps  and  are  sometimes  forced  out 
from  the  uterus.  Sub-peritoneal  tumors  become  smaller. 

The  treatment  of  pregnancy  complicated  by  fibroid  tumors 
of  the  uterus  depends  upon  the  circumstances  of  the  individual 
case.  If  the  patient  be  in  good  condition  and  the  tumor  is  so 
situated  that  it  will  afford  an  obstacle  to  birth,  myomectomy 
may  be  performed  in  the  interests  of  mother  and  child.  If 
the  tumor  fills  the  pelvis  and  myomectomy  is  impossible, 
an  effort  may  be  made  to  displace  the  tumor,  allowing  the 
child  to  descend,  and  if  such  fails  delivery  by  section  with 
hysterectomy  is  indicated.  In  cases  where  a  fibroid  tumor  is 
large  and  surrounds  the  uterine  cavity,  pregnancy  may  su- 
pervene and  may  not  be  detected  until  hysterectomy  is  per- 
formed. Fibroid  tumors  may  exert  a  very  unfavorable 
influence  upon  pregnancy  by  causing  profound  anemia.  In 


136 


MANUAL   OF   OBSTETRICS 


these  cases  medical  treatment  may  be  of  service,  and  should 
this  fail  myomectomy  or  hysterectomy  must  be  performed. 

Cancer  of  the  uterus  complicating  pregnancy  usually 
grows  very  rapidly.  The  extirpation  of  the  uterus  is  indi- 
cated so  soon  as  the  diagnosis  is  made.  In  cases  where  the 
condition  is  not  discovered  until  the  child  is  viable,  a  brief 


Fig.  36. — Pregnancy  complicated  by  uterine  fibroids. 

delay  may  be  permitted,  the  mother  being  in  good  condition, 
to  secure  established  viability.  The  children  in  these  cases 
are  usually  ill-nourished  and  weak,  and  hence  in  early  preg- 
nancy no  effort  should  be  made  to  preserve  the  life  of  the 
fetus. 

Malformations  of  the  Generative  Organs. — In  some  cases 
where  the  uterus  has  failed  to  develop  normally  the  original 


ABNORMAL    CONDITIONS    OF    PELVIC    ORGANS  137 

partition  between  the  two  halves  remains,  and  a  so-called 
double  uterus  results.  An  impregnated  ovum  may  lodge  in 
one  of  these  cavities,  leaving  the  other  empty.  Should  uter- 
ine development  permit,  pregnancy  may  go  to  term  and  a 
living  child  be  delivered.  Should  there  be  danger  of  uterine 
rupture  the  patient  should  be  delivered  by  section.  Mal- 
formations in  the  lower  portion  of  the  generative  tract  are 
sometimes  observed  and  must  be  dealt  with  in  accordance 
with  the  nature  of  each  case. 

Malpositions  of  the  Pelvic  Viscera  Complicating  Preg- 
nancy.— A  frequent  and  often  serious  complication  of  preg- 
nancy is  retroversion  of  the  uterus.  This  may  have  preceded 
conception,  the  patient  not  being  aware  of  the  condition  until 
the  growth  of  the  uterus  caused  pain.  In  other  cases  the 
uterus  was  not  originally  retroverted,  but  in  the  first  weeks 
of  pregnancy  became  so,  often  through  a  sudden  effort  at 
lifting  or  straining. 

While  a  retroverted  pregnant  uterus  may  develop  normally 
for  a  short  time,  its  increase  in  size  must  sooner  or  later  cause 
pain  and  distress,  thus  drawing  attention  to  the  condition. 

Among  the  most  pronounced  symptoms  is  irritability  of  the 
bladder.  A  retroverted  womb  makes  traction  upon  the 
fascia  and  pelvic  peritoneum  about  the  bladder,  in  some  cases 
almost  occluding  the  urethra.  Retention  of  urine  frequently 
results,  unless  care  be  taken  to  empty  the  bladder  by  cathe- 
ter. Enormous  distention  may  gradually  result  with  de- 
composition of  the  urine,  and  severe  cystitis.  Abortion  fre- 
quently results  from  pressure  upon  the  growing  uterus,  while 
the  ovum  may  die  within  the  womb  and  finally  be  expelled 
as  a  blighted  ovum. 

The  diagnosis  of  retroversion  of  the  pregnant  womb  is 
made  by  combined  examination,  the  outward  hand  placed 
behind  the  pubis  failing  to  find  the  fundus.  Internal  ex- 
amination shows  a  softened  cervix  directed  upward  behind 
the  pubis,  while  the  fundus  fills  the  space  in  the  posterior  wall 
of  the  pelvis.  It  is  usually  possible  to  make  out  the  lower 
uterine  segment,  except  in  neglected  and  infected  cases. 

Treatment. — A  pregnant  patient  with  retroversion  should 
be  put  to  bed  if  possible,  under  the  care  of  a  nurse.  She 
should  lie  upon  her  side,  and  the  nurse  should  see  that  the 


138  MANUAL    OF   OBSTETRICS 

patient's  urinary  bladder  is  frequently  emptied.  The  bowel 
should  be  completely  emptied  by  high  injection,  and  the 
patient  given  liquid  food  with  toast.  An  effort  should  be 
made  to  replace  the  uterus  by  placing  the  patient  in  the  knee- 
chest  posture,  and  with  two  fingers  carrying  the  uterus  to  one 
side  of  the  promontory  of  the  sacrum  and  forcing  the  fundus 
up  above  the  brim  of  the  pelvis.  Should  this  effort  give  the 
patient  much  pain  the  obstetrician  must  desist.  When  the 
uterus  cannot  be  immediately  replaced  a  continuous  but  very 


Fig.  37. — Replacing  the  pregnant  womb  when  retroverted  (after  Bumm). 

gentle  effort  should  be  made  by  inserting  tampons  of  carded 
wool  soaked  in  one  per  cent,  lysol,  and  they  should  be  re- 
newed at  least  as  often  as  every  two  days.  When  the  tam- 
pons are  changed  a  vaginal  irrigation  of  one  per  cent,  lysol 
should  be  made.  During  this  treatment  the  patient  should 
be  under  intelligent  care,  and  in  bed  or  on  a  couch,  not 
lying  upon  her  back.  After  the  uterus  has  been  replaced  an 
elastic  soft  rubber  ring  pessary  may  be  worn  to  advantage 
until  the  uterus  is  so  large  that  it  cannot  get  into  the  pelvis. 


ABNORMAL    CONDITIONS    OF    PELVIC    ORGANS  139 

With  this  the  patient  may  usually  resume  her  accustomed  life, 
gradually  avoiding  lifting  and  straining,  and  taking  the  knee- 
chest  posture  night  and  morning  until  the  uterus  is  so  large 
that  it  cannot  enter  the  pelvis. 

Should  the  uterus  remain  in  the  hollow  of  the  sacrum  and 
the  embryo  die,  infection  may  develop  and  a  dangerous  con- 
dition supervene.  In  such  a  case  it  may  be  safest  to  remove 
the  uterus  through  the  vagina  to  save  the  mother  from  fatal 
septic  infection. 

Prolapse  of  the  ovaries,  with  or  without  adhesions,  may 
complicate  pregnancy  and  occasion  severe  pain  as  the  uterus 
increases  in  size.  Beyond  palliation  nothing  can  be  done 
until  the  uterus  has  become  an  abdominal  organ.  Should 
evidences  of  pyosalpinx  be  present,  operation  must  be  under- 
taken, when  the  ovaries  should  be  freed  from  their  adhesions 
and  restored  to  their  normal  place. 

Prolapse  of  the  pelvic  viscera  may  interfere  with  the  flor- 
mal  course  of  pregnancy,  expose  the  mother  to  considerable 
suffering,  and  threaten  abortion.  It  is  usually  best  to  pal- 
liate in  these  cases,  keeping  the  uterus  within  the  pelvis  by 
tampons  until  its  growth  is  such  that  it  cannot  prolapse. 
Operation  and  permanent  cure  should  be  undertaken  when 
the  patient  has  recovered  from  parturition. 

Hernia,  abdominal,  inguinal  or  pelvic,  complicating  preg- 
nancy, can  usually  be  controlled  by  pads  or  trusses  until 
pregnancy  has  terminated.  In  urgent  cases  operation  must 
be  undertaken. 

Atresia. — In  patients  who  have  had  severe  previous  infec- 
tion, or  who  are  badly  developed,  the  cervix,  vagina  or  vulva 
may  be  largely  occluded  and  spontaneous  birth  impossible. 
Patients  occasionally  come  into  labor  without  any  discern- 
ible external  os.  Careful  examination  discloses  a  small 
aperture,  admitting  a  probe.  Under  anesthesia  this  should 
be  gradually  enlarged,  and  if  it  does  not  readily  yield  to  sat- 
isfactory dilatation  the  cervix  should  be  deeply  incised,  and 
birth  accomplished.  Where  the  cervix,  vagina,  pelvic  floor 
and  vulva  have  been  the  site  of  some  destructive  inflamma- 
tion preceding  pregnancy,  the  parts  may  be  so  contracted 
and  so  incapable  of  dilatation  that  delivery  by  section  may 
become  necessary. 


140  MANUAL    OF   OBSTETRICS 

Abnormal  Conditions  in  the  Pelvic  Viscera  Resulting  from 
Previous  Operation. — Operations  undertaken  to  secure  dis- 
location or  diseased  conditions  of  the  pelvic  viscera  may 
leave  the  patient  in  such  condition  that  pregnancy  cannot 
go  to  term,  and  spontaneous  birth  becomes  impossible. 

The  various  operations  done  to  cure  prolapse  and  dislocation 
of  the  uterus  often  cause  serious  trouble  in  pregnancy.  Ven- 
tro-suspension  and  ventro-fixation  produce  most  serious  com- 
plications. Here  the  anterior  uterine  wall  is  so  greatly  lim- 
ited in  mobility  and  development  that  the  fetus  grows  in  the 
posterior  portion  of  the  uterus  and  may  over-stretch  the 
posterior  uterine  wall  to  the  point  of  rupture.  To  attempt 
to  deliver  the  child  through  the  vagina  is  always  dangerous, 
and  delivery  by  abdominal  section  is  indicated.  Adhesions 
should  then  be  severed  and  the  uterus  brought  into  proper 
position.  If  this  cannot  satisfactorily  be  done  the  operator 
must  perform  hysterectomy. 

Prolapse  of  the  pelvic  viscera,  complicating  pregnancy 
and  preceding  it,  may  be  permanently  cured  by  delivering 
the  patient  by  section  at  full  term,  removing  the  body  of  the 
uterus  and  fastening  the  stump  in  the  lower  end  of  the  ab- 
dominal incision  with  a  clamp  or  by  suture.  With  this  po- 
sition the  uterine  stump  draws  the  prolapsed  tissue  upward, 
the  broad  ligaments  are  also  drawn  above,  and  a  firm  scar 
forms  at  the  lower  end  of  the  abdominal  incision,  which 
effectually  prevents  prolapse  and  cures  the  condition. 

ABORTION 

By  abortion  is  understood  the  expulsion  of  the  product 
of  conception  before  viability — 26  weeks.  Patients  dislike 
the  word  abortion  because  they  hear  of  criminal  abortion,  and 
they  constantly  use  the  word  miscarriage  instead.  Pre- 
mature labor  is  the  expulsion  of  the  fetus  after  viability  and 
before  full  term. 

The  Causes  of  Abortion. — This  may  be  maternal,  paternal 
or  embryonal.  Maternal  causes  are  largely  those  diseased 
conditions  of  the  endometrium  which  prevent  the  formation 
of  normal  decidua  and  the  adhesion  of  the  ovum.  The 
pathology  of  this  condition  is  the  pathology  of  endometritis. 
Diseased  conditions  of  other  viscera  which  influence  the 


ABORTION  141 

endometrium  may  indirectly  cause  abortion,  such  as  chronic 
nephritis,  gout,  and  syphilis. 

Dislocation  of  the  uterus,  which  renders  normal  uterine 
growth  impossible  may  cause  abortion;  so  also  may  the 
growth  of  pelvic  tumors.  Direct  violence  to  the  mother  by 
lifting  or  straining  or  disturbance  of  the  genital  tract,  or 
traumatism  by  a  fall,  a  blow,  or  other  injury,  may  produce 
abortion.  Prolonged  high  temperature  in  acute  infectious 
disease  so  destroys  the  oxygenating  power  of  the  mother's 
blood  as  to  cause  abortion.  An  unstable  condition  of  the 
nervous  system  may  produce  such  irritability  of  the  uterine 
muscle  that  it  contracts  upon  very  slight  disturbance  and  ex- 
pels the  embryo.  Exertion  during  times  when  menstruation 
should  have  occurred  may  produce  congestion  in  the  pelvic 
viscera,  followed  by  apoplexy  in  the  ovum  and  abortion. 
Improper  and  tightly  applied  clothing  may  force  the  uterus 
out  of  position  and  cause  it  to  expel  its  contents.  Ex- 
tremes of  heat  or  cold  sometimes  produce  abortion.  Shock 
or  great  excitement  may  so  disturb  the  nervous  system  as  to 
destroy  the  embryo.  Chronic  poisoning  or  acute  irritant 
poisons  may  cause  abortion. 

Paternal  Causes  of  Abortion. — Among  the  paternal  causes 
of  abortion,  syphilis  is  the  most  important.  This  so  vitiates 
the  embryo  that  normal  development  is  impossible,  hem- 
orrhage occurs  in  the  chorion,  and  the  embryo  dies  and  is 
expelled.  Chronic  poisoning  in  the  father  and  a  chronically 
debilitated  condition  may  render  the  impregnated  ovum  in- 
capable of  prolonged  development. 

Ovular  Causes  of  Abortion. — Abnormalities  in  the  develop- 
ment of  the  embryo  may  render  its  complete  growth  im- 
possible. By  far  the  most  frequent  ovular  cause  of  abortion 
is  hemorrhage,  usually  in  the  chorion.  Syphilis  may  pro- 
duce this,  chronic  poisoning  from  acute  infection,  or  toxemia 
may  bring  this  about. 

The  mechanism  of  abortion  is  usually  the  same,  with 
hemorrhage  into  the  placental  decidua  and  into  the  chorion, 
followed  by  separation  of  the  ovum  from  the  uterine  wall, 
with  its  death  and  subsequent  expulsion. 

The  Blighted  Ovum. — While  the  impregnated  ovum  has 
died,  it  can  still  be  retained  within  the  uterus.  It  is  then 


142  MANUAL   OF   OBSTETRICS 

termed  a  blighted  ovum.  If  it  is  expelled  the  process  is  said 
to  be  abortion.  The  retention  of  a  blighted  ovum  is  more 
dangerous  than  abortion  because  the  syncytium  covering 
the  villi  of  the  chorion  may  not  die  but  proliferate,  attacking 
the  mother's  tissue  and  producing  syncytioma  malignum. 
The  retention  of  fetal  tissue  within  the  uterus  is  dangerous 
because  it  tends  to  produce  malignant  growth,  and  hence  all 
such  tissue  should  be  expelled  as  soon  as  possible  after  the 
death  of  the  ovum. 

Tubal  Abortion. — When  the  impregnated  ovum  lodges  in 
the  Fallopian  tube  and  its  development  distends  the  tube,  if 
the  ovum  be  near  the  fimbriated  extremity  the  muscular  and 
elastic  tissue  of  the  tube  may  contract  and  force  the  ovum 
through  the  fimbriated  extremity.  Such  is  called  tubal 
abortion.  Rarely  the  ovum  attaches  itself  to  pelvic  or  ab- 
dominal tissues,  and  may  develop  to  term.  It  is  usually 
destroyed  by  the  cells  of  the  peritoneum. 

The  Diagnosis  of  Abortion. — The  cardinal  symptoms  of  this 
accident  are  pain  and  hemorrhage.  The  pain  is  usually 
low  in  the  back,  radiating  to  the  front.  It  is  severe  in  pro- 
portion to  the  vigor  of  uterine  contractions.  It  may  resem- 
ble the  pain  of  lumbago,  or  the  suffering  produced  by  intes- 
tinal colic.  Like  a  miniature  labor,  the  pains  increase  in 
intensity  until  the  expulsion  of  the  ovum,  when  relief  usually 
follows.  The  hemorrhage  hi  abortion  is  bright  in  color,  the 
blood  clotting  if  the  ovum  has  but  recently  separated  from 
the  uterine  wall.  If,  however,  separation  has  been  going  on 
gradually,  and  the  ovum  is  partly  attached,  or  if  separation 
occurred  at  some  previous  time  and  the  blood  was  retained, 
the  blood  will  clot  feebly  and  be  dark  in  color,  resembling 
prune  juice.  The  amount  of  the  hemorrhage  varies  in  ac- 
cordance with  the  physical  characteristics  of  the  mother  and 
the  extent  of  the  separation  of  the  ovum.  Hemorrhage  is 
rarely  so  great  as  to  produce  syncope  or  to  threaten  life. 

The  Differential  Diagnosis. — Abortion  must  be  differen- 
tiated from  painful  menstruation,  menorrhagia  or  metro- 
rrhagia.  In  painful  menstruation  pain  and  hemorrhage  occur 
at  the  regular  tune,  there  is  no  previous  history  or  symptom 
of  pregnancy,  and  the  blood  discharged  does  not  clot. 

Abortion  is  frequently  accompanied  by  free  hemorrhage 


PLATE  I 


Abortion  at  eighteen  weeks,  fetus  and  placenta  20  cm.  long  (Davis, 
Treatise  on  Obstetrics). 


ABORTION  143 

and  this  may  be  confused  with  menorrhagia,  but  in  the  latter 
there  is  no  history  of  pregnancy  and  no  previous  symptoms. 
The  character  of  the  discharge  is  also  of  value  in  making  the 
diagnosis.  In  metrorrhagia  there  is  a  history  of  endometritis, 
of  fibroid  growth  in  the  uterus,  malignant  disease,  or  some 
other  condition  which  accounts  for  the  bleeding. 

Threatened,  Inevitable  and  Incomplete  Abortion. — By 
threatened  abortion  is  understood  pain  and  hemorrhage 
which  gradually  ceases  without  the  death  or  expulsion  of 
the  embryo.  By  inevitable  abortion  is  understood  pain  and 
hemorrhage  which  cannot  be  made  to  cease  and  which  finally 
culminate  in  abortion.  By  incomplete  abortion  we  under- 
stand the  retention  in  the  uterus  of  some  portion  of  the  ovum 
or  its  appendages. 

The  habit  of  abortion,  or  chronic  abortion,  is  sometimes 
used  to  designate  the  condition  of  the  pelvic  organs  and  the 
general  health  of  the  patient,  which  makes  a  continuance  of 
pregnancy  impossible.  It  is  sometimes  difficult  to  find  an 
anatomical  cause  for  this  abnormality.  Conception  occurs 
and  pregnancy  goes  to  a  certain  point  and  then  terminates; 
and  in  repeated  pregnancies  the  same  accident  happens. 
Among  animals  epidemic  abortion  may  usually  be  traced 
to  septic  infection,  but  in  the  human  subject  the  habit  of 
abortion  is  often  inexplicable. 

Pathology. — The  essential  pathology  of  abortion  is  hem- 
orrhage into  the  decidua  or  chorion.  Extravasated  blood 
acts  as  a  foreign  body  and  produces  additional  hemorrhage 
and  separation  of  the  ovum  from  the  uterine  wall.  While 
the  mother  is  sound  and  the  initial  separation  has  resulted 
from  violence,  the  blood  may  clot,  further  hemorrhage  be 
prevented,  and  sufficient  of  the  embryo  remain  adherent  to 
secure  its  further  development.  Acute  infections  produce 
hemorrhage  and  separation  by  their  destructive  influence 
upon  the  blood.  Diseased  conditions  of  the  endometrium 
lead  to  degeneration  of  capillaries  and  extravasation  of  blood. 
Abnormalities  in  embryonal  development  may  cause  apoplexy 
in  the  chorion  and  separation.  The  fact  that  the  embryo  is 
frequently  expelled  enveloped  in  a  blood-clot  should  em- 
phasize the  essential  nature  of  the  pathology  of  abortion. 


144  MANUAL   OF   OBSTETRICS 

The  Prevention  of  Abortion. — Abortion  may  be  prevented 
by  removing  its  cause.  Most  common  of  those  which  can 
be  controlled  is  direct  disturbance  of  the  generative  tract. 
Among  working  women,  lifting  and  straining  are  frequently 
followed  by  abortion.  The  enactment  of  laws  which  pre- 
vent the  employment  of  pregnant  women  in  laborious  occupa- 
tions endeavors  to  remove  a  frequent  cause  of  abortion. 
Second  only  in  importance  to  the  avoidance  of  direct  me- 
chanical violence  is 'the  doing  away  with  those  causes  which 
produce  great  mental  or  nervous  disturbance.  Mental 
shock  or  continued  anxiety  may  result  in  the  death  or  ex- 
pulsion of  the  embryo.  The  need  of  absolute  rest  is  shown 
in  those  cases  of  repeated  abortion  where  a  patient  does  not 
pass  through  pregnancy  successfully  until  she  is  made  to  re- 
main in  bed  for  weeks  or  even  months. 

The  general  care  of  the  pregnant  patient  is  most  important 
in  preventing  abortion.  The  regulation  of  clothing,  the 
avoidance  of  toxemia  by  proper  food  and  attention  to  di- 
gestion and  excretion,  the  avoidance  of  very  hot  or  very  cold 
baths,  the  insistence  upon  a  normal  physiological  life,  all 
tend  to  prevent  abortion. 

A  pelvic  examination  should  be  made  in  each  case  of  early 
pregnancy  to  determine  that  the  uterus  is  in  normal  posi- 
tion so  that  it  may  develop  without  interrupting  pregnancy. 
The  patient,  to  avoid  abortion,  must  exercise  especial  care  at 
those  times  when  menstruation  would  otherwise  have  oc- 
curred. Rest  in  bed  for  several  days  and  the  avoidance  of 
all  strain  and  exertion  are  imperative.  Those  circumstances 
which  generally  exhaust,  depress  and  excite,  are  to  be  avoided 
if  abortion  is  to  be  prevented.  The  pregnant  patient  should 
not  go  into  great  crowds,  nor  take  long  and  uncomfortable 
journeys,  nor  be  shocked  by  horrifying  spectacles  or  other 
depressing  influences. 

A  belief  that  abortion  can  be  avoided  is  often  a  powerful 
factor  in  preventing  it.  Drugs  are  of  value  only  in  so  far  as 
they  calm  the  nervous  system  or  correct  diseased  conditions. 
The  most  prolonged  effects  produced  by  drugs  are  seen  in  the 
treatment  of  syphilis,  or  of  the  acute  infectious  disorders 
where  drugs  destroy  the  infective  organism,  and  thus  pre- 
vent abortion.  Much  can  be  done  to  prevent  abortion  if 


ABORTION  145 

simple  directions  by  reputable  medical  men  are  circulated 
freely  among  married  women. 

The  Treatment  of  Abortion. — The  Treatment  of  Threat- 
ened Abortion. — When  abortion  threatens,  the  patient  must 
be  put  at  absolute  rest  under  competent  care.  Opium  in  the 
form  of  rectal  suppositories  containing  from  }/£  to  1  grain  of 
the  aqueous  extract  should  be  inserted  in  the  rectum  suffi- 
ciently often  to  quiet  pain.  If  the  patient  can  retain  it  she 
should  be  given  by  the  mouth  bromide  of  sodium  with  tinc- 
ture of  hyoscyamus  and  fluid  extract  of  viburnum  pruni- 
folium.  If  the  stomach  rejects  this,  a  suppository  contain- 
ing codein,  hyoscyamus  and  viburnum  may  be  used  instead. 
Easily  digested  liquid  food  must  be  taken,  and  all  interrup- 
tion and  disturbance  should  be  absolutely  prohibited.  The 
patient  should  use  a  bed-pan  and  remain  absolutely  quiet. 
Soiled  dressings,  clots  and  other  material  expelled,  must  be 
saved  for  the  inspection  of  the  attending  physician.  If  the 
ovum  does  not  entirely  separate,  but  remains  sufficiently 
adherent  to  live,  hemorrhage  will  gradually  cease,  pain  will 
disappear,  and  pregnancy  go  on.  Should  hemorrhage  con- 
tinue and  grow  more  profuse,  pain  becomes  stronger  and  more 
rhythmical,  the  ovum  will  be  expelled  and  abortion  is  in- 
evitable. 

The  Treatment  of  Inevitable  and  Incomplete  A  bortion. — So 
soon  as  it  is  evident  that  abortion  is  inevitable,  measures 
must  be  taken  to  secure  the  entire  expulsion  of  the  ovum  and 
decidua  to  control  hemorrhage  and  to  prevent  infection. 
Anesthesia  is  often  required  for  this  purpose  if  the  patient's 
condition  justifies  it.  Under  antiseptic  precautions  the  vagina 
should  be  thoroughly  sponged  out  with  1  per  cent,  lysol,  the 
bladder  emptied  by  catheter,  the  cervix  seized  by  tenaculum 
forceps  and  dilated  sufficiently  by  solid  dilators,  if  necessary, 
to  permit  the  introduction  of  one  or  two  fingers.  If  the  fingers 
of  the  gloved  hand  cannot  reach  the  fundus,  a  large  blunt-edged 
spoon-shaped  curette  may  be  gently  passed  over  the  uterine 
wall  and  whatever  is  not  attached  brought  away.  The  uterus 
may  then  be  gently  but  thoroughly  irrigated  with  1  per  cent, 
lysol,  and  tamponed  firmly  with  10  per  cent,  iodoform  gauze. 
The  vagina  should  be  sponged  clean  with  gauze  and  a  vaginal 
packing  of  bichloride  gauze  inserted. 


146  MANUAL   OF   OBSTETRICS 

The  pressure  of  the  gauze  brings  about  the  prompt  and  early 
discharge  of  the  ovum  and  decidua,  prevents  hemorrhage, 
and  the  gauze  acts  as  a  drain.  Liquid  food,  laxatives,  tonic 
doses  of  strychnia  and  ergot,  and  antiseptic  care,  are  needed. 
The  gauze  may  be  removed  in  from  forty-eight  to  sixty  hours 
after  its  insertion  and  portions  of  the  ovum  and  decidua  will 
usually  be  found  adherent  to  it.  Only  a  vaginal  douche  is 
needed  when  the  gauze  is  removed.  No  douche  should  after- 
wards be  given.  If  all  of  the  ovum  has  not  been  discharged 
the  remaining  fragments  will  be  expelled  without  difficulty 
in  a  few  days.  During  convalescence  the  patient  should  wear 
antiseptic  vulvar  dressings,  and  should  be  kept  thoroughly 
clean  with  antiseptic  solution.  As  much  attention  should  be 
given  to  the  mother's  complete  recovery  as  if  she  had  had 
parturition  at  full  term.  Subinvolution  often  occurs,  be- 
cause the  mother  misses  the  stimulus  of  the  nursing  child  to 
secure  uterine  contraction.  If  infection  develops,  adhesions 
and  thickening  of  the  pelvic  tissues  may  be  the  consequence. 
Before  discharging  the  patient  as  cured  a  bimanual  examina- 
tion should  be  made  to  ascertain  her  condition. 

The  Treatment  of  Chronic  Abortion — When  a  patient 
habitually  aborts,  a  very  thorough  examination  of  both  hus- 
band and  wife,  if  possible,  is  necessary.  In  the  case  of  the 
husband,  syphilis  or  other  chronic  poisoning  must  be  ex- 
cluded, and  it  must  be  ascertained  that  he  is  in  good  general 
health. 

In  the  case  of  the  wife,  the  condition  of  the  reproductive 
organs  must  be  ascertained  as  accurately  as  possible.  If  the' 
uterus  is  not  in  normal  position  it  must  be  restored,  and  if 
chronic  inflammation  be  present  in  the  pelvic  organs,  this 
must  receive  attention.  Most  cases  require  a  thorough  dila- 
tation under  ether,  followed  by  curetting,  with  the  applica- 
tion of  an  astringent  and  alterative,  such  as  tincture  of  iodine. 

The  mother's  general  health  must  receive  attention,  and 
anemia  or  gout  or  chronic  infection  of  any  nature  must  be 
dealt  with.  If  the  patient  be  nervous  and  apprehensive  she 
must  be  built  up  in  every  possible  way. 

A  careful  history  is  required  in  these  cases  to  ascertain  at 
what  period  of  gestation  abortion  has  occurred.  If  preg- 
nancy follows  the  treatment,  the  patient  should  be  put  at 


ABORTION  147 

rest  in  bed  for  several  weeks  before  and  after  the  time  of 
previous  abortion.  It  is  often  necessary  to  confine  the  pa- 
tient to  bed  for  the  first  four  months  of  pregnancy.  Much 
can  be  done  if  patients  are  instructed  as  to  what  is  dangerous 
to  pregnancy,  and  how  to  so  order  their  lives  as  to  reduce  the 
danger  of  abortion  to  the  lowest  possible  degree. 

Therapeutic  Abortion. — When  the  continuation  of  preg- 
nancy threatens  the  mother's  life,  pregnancy  must  be  ended. 
This  decision  must  be  accepted  by  the  patient  and  must  not 
be  made  until  the  obstetrician  is  sure  of  his  ground,  and  if 
necessary  consultation  should  be  held.  If  the  patient  has 
conscientious  scruples  against  interrupting  pregnancy,  the 
responsibility  for  its  continuance  becomes  hers. 

Patients  requiring  therapeutic  abortion  are  usually  greatly 
reduced  in  strength  and  the  power  of  resistance.  Anesthesia 
is  necessary,  but  such  should  not  be  prolonged,  and  ether 
should  be  employed  well  diluted  with  oxygen.  Under  anti- 
septic precautions  the  cervix  should  be  dilated  sufficiently 
to  introduce  one  or  two  fingers.  No  effort  should  be  made  to 
curette  the  uterus,  but  after  dilatation  its  cavity  should  be 
firmly  packed  with  10  per  cent,  iodoform  gauze  and  the  vagina 
tamponed  to  conclude  the  operation. 

This  procedure  immediately  destroys  the  life  of  the  ovum, 
and  in  cases  of  pernicious  nausea  usually  ends  the  nausea  at 
once.  The  gauze  may  be  allowed  to  remain  for  from  forty- 
eight  to  sixty  hours,  when  the  ovum  will  come  away  with  it 
or  be  discharged  shortly  afterward.  The  decidua  may  not 
be  entirely  expelled  for  several  days.  Under  antiseptic  pre- 
cautions and  with  antiseptic  dressings  afterward,  infection 
should  not  follow  this  procedure. 

The  other  methods  of  inducing  therapeutic  abortion  are 
too  uncertain,  too  slow,  and  too  apt  to  cause  infection,  to  be 
worthy  of  trial. 

Criminal  Abortion. — The  term  criminal  abortion  is  applied 
to  the  wilful  destruction  of  the  embryo  without  adequate 
cause.  It  is  done  in  cases  of  illegitimate  pregnancy,  or  where 
married  women  will  not  allow  pregnancy  to  continue. 

The  method  of  producing  criminal  abortion  varies,  but  in 
most  cases  a  sound  or  rod  of  some  sort  is  thrust  into  the  uterus. 
This  pierces  the  envelope  of  the  embryo,  often  wounding  the 


148 


MANUAL   OF   OBSTETRICS 


decidua,  causing  hemorrhage  and  the  death  of  the  embryo. 
Criminal  abortionists  make  no  effort  to  remove  the  product 
of  conception,  but  aim  solely  to  destroy  its  life.  Women 
often  attempt,  and  sometimes  produce,  abortion  upon  them- 
selves by  introducing  pieces  of  whalebone  or  wire  within  the 
uterus. 


Fig.  38. — Perforation  of  a  retroflexed  uterus  by  u  curette,  introduced  to 
bring  on  abortion  (Liepmann). 


Following  criminal  abortion  there  is  usually  severe  and 
often  prolonged  hemorrhage.  As  few  abortionists  practice 
antiseptic  precautions  infection  frequently  occurs.  As  every 
effort  is  made  to  conceal  the  crime  the  patient  does  not  obtain 
competent  medical  advice  until  she  is  severely  ill,  hence  the 


ABORTION  149 

mortality  and  morbidity  of  criminal  abortion  must  remain 
high.  Death  usually  occurs  from  septic  infection  and  its 
complications,  and  should  recovery  follow  the  patient  is 
often  left  with  chronic  pelvic  peritonitis  and  its  consequences. 
Foreign  bodies  are  sometimes  thrust  through  the  vagina  into 
the  abdominal  cavity,  into  the  bladder  or  rectum,  and  various 
injuries  follow  attempts  at  abortion. 

When  a  patient  in  the  child-bearing  age  is  brought  to  the 
attention  of  a  physician  with  the  symptoms  of  pelvic  peri- 
tonitis and  with  a  vaginal  discharge  of  bloody  fluid,  criminal 
abortion  must  be  suspected.  The  physician  should  first  co- 
operate with  the  authorities  of  his  city  or  town  and  notify 
them  that  he  has  been  summoned  to  the  case,  without  neces- 
sarily giving  the  name  of  the  patient.  This  should  be  done 
so  that  if  possible  a  clue  can  be  obtained  to  the  perpetrator 
of  the  offense,  but  the  treatment  given  by  a  reputable  physi- 
cian should  not  in  any  way  injure  the  patient.  As  these 
patients  are  infected,  they  require  tonic  and  stimulant  treat- 
ment. No  effort  should  be  made  to  operate  upon  them  un- 
less the  indications  are  pressing.  By  the  time  they  are  seen 
by  a  reputable  physician  the  blood  has  become  infected,  so 
that  local  treatment  is  of  little  value.  If  the  patient  sur- 
vives the  operation,  but  remains  with  a  normal  temperature 
for  some  time,  she  should  be  thoroughly  examined  to  ascer- 
tain the  condition  of  the  pelvic  organs.  Or  if  she  survives 
abortion  and  develops  pyosalpinx  or  pelvic  abscess,  it  is  evi- 
dent that  pus  must  be  evacuated  from  the  pelvis  or  an  in- 
fected tube  removed.  Should  the  patient  become  critically 
ill  the  legal  authorities  must  be  immediately  notified  and  all 
information  possible  obtained  to  trace  the  criminal. 

The  duty  of  the  physician  in  these  cases  is  often  difficult, 
for  he  must  not  betray  the  patient's  confidence,  and  yet  he 
must  not  shield  the  abortionist.  Criminal  abortion  is  a 
crime  punishable  in  most  states  by  imprisonment  and  fine, 
and  should  be  considered  a  crime  by  the  medical  profession. 
No  reputable  physician  can  think  of  such  a  procedure. 


PART  III 
LABOR 

By  labor   is   meant   the   spontaneous   expulsion   from   the 
mother's  body  of  the  fetus  and  its  appendages. 


CHAPTER  XI 
THE  CAUSES  AND  TREATMENT  OF  LABOR 

Various  theories  have  been  advanced  to  explain  the  causa- 
tion of  labor,  but  that  which  is  most  reasonable  recognizes 
the  toxemic  state  of  the  mother's  blood  from  materials  de- 
rived from  both  fetal  and  maternal  tissues  to  be  the  exciting 
cause.  This  irritates  the  nervous  system  and  fetal  move- 
ments excite  uterine  contractions  and  bring  on  fetal  expulsion. 
Unquestionably  changes  in  the  placenta  by  which  its  vessels 
become  to  some  extent  obliterated,  tend  to  excite  partial 
asphyxiation  in  the  fetus,  producing  violent  motions  and 
exciting  labor.  Labor  may  also  be  caused  by  mental  and 
nervous  excitement  and  by  the  action  of  some  drugs,  as  pur- 
gatives, notably  castor  oil. 

Labor  usually  occurs  at  what  would  have  been  a  men- 
strual crisis  had  the  patient  not  conceived.  Just  preceding 
menstruation  the  blood  pressure  is  usually  increased  and  this 
aids  in  exciting  labor.  In  attempting  to  compute  the  time 
of  labor,  one  must  ascertain  the  patient's  individual  history 
concerning  menstruation— what  her  average  intervals  have 
been,  and  what  the  duration  and  character  of  menstruation 
has  also  been.  Many  patients  who  have  children  repeatedly 
show  a  tendency  to  come  into  labor  at  the  same  hour  in  the 
twenty-four,  and  some  terminate  pregnancy  at  practically 
the  same  day  at  each  confinement. 

150 


VERTEX    PRESENTATION 


151 


THE  MECHANISM  OF  LABOR 


By  the  mechanism  of  labor  we  understand  the  adaptation 
of  the  fetus  to  the  mother's  birth  canal  and  the  phenomena 
which  accompany  its  expulsion.  As  the  vertex  most  often 
presents  the  mechanism  of  this  labor  must  first  be  considered. 


• 

Fig.  39. — First  position,  vertex  presentation  before  rotation  has  begun. 


VERTEX  PRESENTATION 

The  Stages  of  Labor. — Labor  is  commonly  divided  into  a 
first,  second  and  a  third  stage. 

The  first  ends  when  the  cervix  is  completely  dilated, 
whether  or  not  the  membranes  have  ruptured.  The  second 
terminates  with  the  expulsion  of  the  fetus;  the  third  with  the 
delivery  of  the  fetal  appendages. 

While  during  the  first  stage  there  seems  to  be  little  of  a 
mechanical  nature,  the  important  phenomenon  of  engagement 


152  MANUAL    OF   OBSTETRICS 

and  descent  are  then  developed.  By  engagement  is  meant  the 
fitting  of  the  presenting  part  into  the  patient's  pelvis.  To 
accomplish  this  the  head  must  be  so  placed  that  its  shorter 
and  not  its  longest  diameters  will  be  brought  in  relation  with 
the  pelvic  brim.  As  there  is  the  most  room  in  the  oblique 
diameters  of  the  pelvic  brim,  so  the  fetal  head  will  engage  and 
descend  in  these  diameters.  This  is  made  possible  by  the 
flexion  of  the  fetal  head  which  brings  the  occipito-frontal  di- 


Fig.  40. — Fitting  the  head  into  the  pelvis. 

ameter  123^  to  12%  cm.  in  relation  with  the  right  oblique 
at  the  pelvic  brim  12^  to  13  cm.  In  the  left  diameter  of  the 
pelvic  brim  is  engaged  the  biparietal  diameter  of  the  head. 
Flexion  is  promoted  by  the  resistance  which  the  chin  experi- 
ences as  it  impinges  against  the  posterior  wall  of  the  pelvis. 
This  forces  the  chin  against  the  sternum  of  the  fetus  and  de- 
velops flexion  fully.  Engagement  is  complete  in  proportion 
as  Iftexion  is  thoroughly  developed  and  the  head  descends 


VERTEX    PRESENTATION 


153 


Fig.  41. — Spontaneous  labor,  head  engaging. 


Fig.  42. — Complete  flexion  with  descent;  first  position,  vertex 
presentation. 


154  MANUAL   OF   OBSTETRICS 

through  the  pelvic  brim.  Engagement  cannot  be  said  to  be 
complete  with  the  head  merely  lodged  in  the  pelvic  brim  and 
showing  no  evidence  of  descent. 

Under  the  influence  of  repeated  and  increasing  uterine 
contractions  the  head  enters  the  pelvic  cavity.  Here  there  is 
room  for  the  turning  of  the  head  in  its  flexed  position  in  any 
direction.  The  descent  of  the  head  through  the  pelvic  brim 
has  been  followed  by  engagement  of  the  shoulders.  The  bis- 
acromial  diameter  entering  in  the  left  oblique  diameter  of  the 
pelvic  brim  passes  down  through  the  pelvic  cavity;  the  head 
reaches  the  pelvic  floor  upon  which  it  at  first  rests  obliquely. 


Fig.    43. — Descent;    occiput    beneath    the    pubes;     rotation   almost 

complete. 

During  its  passage  it  may  have  borne  against  the  side  of  the 
pelvic  wall  in  front  of  the  spines  of  the  ischia,  the  contour  of 
the  pelvic  wall  favoring  its  anterior  rotation.  At  the  pelvic 
floor  the  head  is  exposed  to  two  opposing  forces,  the  down- 
ward pressure  of  uterine  contraction  aided  by  that  of  other 
muscles,  and  the  upward  pressure  of  the  elastic  and  muscular 
tissue  of  the  pelvic  floor.  The  weakest  portion  of  the  pelvic 
floor  is  at  the  entrance  to  the  vagina  beneath  the  pubes.  The 
vertex  naturally  turning  in  the  direction  of  least  resistance 
uncier  the  influence  of  two  opposing  forces  turns  from  left  to 
right,  the  vertex  gradually  distending  the  vulva  and  appear- 


VERTEX   PRESENTATION 


155 


ing  beneath  the  pubes.  Flexion  is  maintained  by  the  re- 
sistance of  the  pelvic  floor  acting  upon  the  face.  As  the  head 
descends  to  the  pelvic  floor  and  appears  in  the  vulva  it  al- 


Fig.  44. — Rotation  complete;  the  head  upon  the  pelvic  floor  and  open- 
ing the  vulva. 

ternately  advances  and  recedes,  the  pains  being  usually 
stronger  and  weaker  in  alternation.  The  vertex  gradually  de- 
scends to  the  vulva  while  the  pelvic  floor  is  drawn  strongly 
upward  to  resist  the  pressure  of  the  head,  which  results  in 


Fig.  45. — The  head  expelled  over  the  pelvic  floor. 

extreme  flexion.  When  the  greater  portion  of  the  head 
emerges  through  the  vulva  the  occiput  is  strongly  pressed 
upward  beneath  the  pubes  and  the  pelvic  floor  gradually  re- 
tracts until  it  passes  over  the  face  and  chin.  The  head  then 


156  MANUAL   OF   OBSTETRICS 

emerges,  the  occiput  immediately  turning  toward  the  left  side 

of  the  mother  toward  which  it  was  directed  within  the  uterus. 

The  shoulders  engaging  in  the  left  oblique  diameter  of  the 

pelvis  pass  through  the  pelvic  cavity,  the  left  or  posterior 


Fig.  46. — The  face  emerging  over  the  pelvic  floor  by  extension. 

shoulder  impinging  upon  the  pelvic  floor,  while  the  right 
lodges  beneath  the  symphysis  pubis.  By  strong  lateral 
flexion  of  the  trunk  the  left  shoulder  is  forced  over  the  pelvic 
floor  and  appears  in  the  vulva,  when  the  right  also  becomes 
dislodged,  and  the  birth  of  the  remainder  of  the  child's  body 


Fig.  47. — The  upper  right  shoulder  pivoting  beneath  the  pubes;  the  left 
posterior  shoulder  on  the  pelvic  floor;  the  occiput  points  to  the  left. 

speedily  follows.  At  the  moment  of  birth  the  child's  back 
is  directed  toward  the  mother's  left  side.  The  essentials  in 
the  mechanism  of  spontaneous  labor  consist  in  the  adapta- 
tion of  the  child  to  the  mother's  birth  canal,  and  its  rotation 


MECHANISM    OF    LABOR   IN   FACE   PRESENTATION         157 

in  the  direction  of  least  resistance  to  permit  its  expulsion. 
The  forces  engaged  are  the  contractile  power  of  the  uterine 
muscle  supplemented  by  all  the  muscles  of  the  trunk,  and  at 
times  by  the  voluntary  use  of  the  upper  and  lower  extremities 
to  steady  and  to  sustain  the  trunk.  Opposing  this  are  the 
elastic  tissue  and  the  muscular  forces  of  the  pelvic  floor. 

The  Mechanism  of  Labor,  Vertex  Presentation,  Second 
Position. — In  the  second  position,  the  mechanism  of  labor  is 
essentially  the  same  as  in  the  first,  excepting  that  the  direc- 
tion of  rotation  is  opposite;  so  in  vertex  presentation,  first 


Fig.  48. — The  right  upper  shoulder  pressed  strongly  against  the  pubes, 
delivering  the  posterior  shoulder  over  the  pelvic  floor. 

position,  the  vertex  rotates  from  left  to  right;  in  the  second 
position  from  right  to  left.  In  vertex  presentation,  first 
position,  the  upper  shoulder  rotates  from  right  to  left;  in 
vertex  presentation,  second  position,  the  upper  shoulder  ro- 
tates from  left  to  right. 

THE  MECHANISM  OF  LABOR  IN  FACE  PRESENTATION 

In  face  presentation  extension  is  substituted  for  flexion. 
The  back  of  the  child  is  directed  toward  the  left  side  of  the 
mother's  body,  the  face  toward  the  left,  and  anteriorly,  the 
chin  toward  the  right,  and  posteriorly.  Complete  extension 
brings  the  depth  of  the  head  at  the  submental  bregmatic 
diameter  hi  relation  with  the  right  oblique  of  the  pelvic 


158 


MANUAL   OF   OBSTETRICS 


brim,  while  the  bitemporal  diameter  is  in  relation  with  the 
left  oblique  of  the  pelvic  brim.     The  shoulders,  as  in  ver- 


Fig.   49. — Face    presenta-  Fig.    50.  —  Face    presentation 

tion,    first    position,  the    hand        without  extension,  constituting  brow 
entering  the  pelvic  cavity.  presentation.     The  descent  of  the 

head  in  this  position  is  impossible. 


Fig.  51. — Face  presentation  with  good  extension,  the  face  on  the  pelvic 
floor,  the  chin  rotated  anteriorly  beneath  the  pubes. 


MECHANISM    OF   LABOR   IN   FACE   PRESENTATION         159 

tex  presentation,  are  in  relation  at  the  left  oblique  of  the 
pelvic  brim.     As  descent  occurs  the  contour  of  the  head  is 


Fig.  52. — Face  presentation;  the  chin  anterior  beneath  the  pubes;  birth 
of  the  head  by  flexion  of  the  cranium  over  the  pelvic  floor. 


Fig.  53. — Face  presentation;  the  face  emerging,  the  head  on  the  pelvic 
floor  distending  the  perineum. 

such  in  extreme  flexion  that  the  chin  first  reaches  and  im- 
pinges strongly  upon  the  pelvic  floor.     The  resistance  which 


160 


MANUAL   OF   OBSTETRICS 


it  encounters  turns  it  in  the  direction  of  least  resistance  and 
it  rotates  beneath  the  pubes,  the  chin  appearing  in  the  vulva. 
The  occiput  rotating  posteriorly  is  in  the  hollow  of  the  sa- 
crum. By  uterine  and  abdominal  pressure  the  chin  is  forced 
tightly  up  beneath  the  pubes  and  by  a  motion  of  flexion  the 
occiput  is  expelled  over  the  pelvic  floor.  The  descent,  en- 
gagement and  expulsion  of  the  shoulders  is  the  same  as  that 
in  vertex  presentation,  first  position.  After  the  head  has 
emerged  it  turns  with  the  face  directed  toward  the  left  side 
of  the  mother. 


Fig.  54. — Face  presentation;  the  head  completely  bom. 


Face  Presentation,  Second  Position. — In  face  presentation, 
second  position,  the  mechanism  is  identical  with  that  of  first 
position,  except  that  the  head  engaging  in  the  left  oblique 
diameter  rotates  from  right  to  left,  while  the  shoulders  en- 
gaging in  the  right  oblique  diameter  rotate  from  left  to  right. 
For  the  mechanism  of  labor  to  be  complete  in  face  presenta- 
tion extreme  extension  must  persist,  otherwise  the  occipito- 
mental  diameter  of  the  head  will  be  brought  in  relation  with 
a  pelvic  diameter  smaller  than  it,  and  impaction  of  the  head 
may  result. 

THE  MECHANISM  OF  LABOR  IN  BREECH  PRESENTATION 

In  breech  presentation  the  bistrochanteric  diameter  of 
the  fetal  body  engages  in  the  right  oblique  of  the  pelvic 


MECHANISM   OF    LABOR   IN   BREECH    PRESENTATION      161 


Fig.  55. — Breech  presentation;  palpating  the  head  in  the  upper  por- 
tion of  the  uterus. 


Fig.  56. — Breech  presentation,  first  position,  with  the  back  anterior. 
ii 


162  MANUAL   OF   OBSTETRICS 

brim  and  readily  descends  to  the  pelvic  floor.  In  the  left 
oblique  diameter  of  the  pelvic  brim  is  the  thickness  of  the 
child's  body,  which  in  normal  cases  is  never  sufficiently 
great  to  interfere  with  the  normal  mechanism  of  labor.  The 
shoulders  of  the  child  and  body  descend  in  the  pelvis,  follow- 
ing the  hips.  At  the  pelvic  floor  the  breech  of  the  child  ro- 
tates from  right  to  left,  the  left  hip  and  thigh  engaging  be- 
neath the  symphysis  pubis,  while  the  right  hip  and  thigh  are 


Fig.  57. — Breech  presentation,  first  position,  with  the  back  posterior. 

forced  downward  over  the  pelvic  floor.  The  shoulders  with 
their  bisacromial  diameter  have  engaged  in  the  right  oblique 
diameter  of  the  pelvic  brim,  and  thus  descend  until  the  pelvic 
floor  is  reached,  when  the  left  anterior  shoulder  rotates  from 
left  to  right  and  engages  beneath  the  pubes,  the  arms  normally 
remaining  flexed  and  closely  applied  to  the  child's  chest. 
The  right  and  posterior  shoulder  passes  over  the  pelvic  floor 
and  the  shoulder  emerges,  the  child's  back  turning  toward  the 


MECHANISM    OF   LABOR   IN   BREECH    PRESENTATION      163 

left  side  of  the  mother's  body.  The  after-coming  head  of  the 
fetus  descends  through  the  pelvic  brim  in  a  flexed  position, 
the  suboccipito-bregmatic  diameter  engaging  in  the  right 
oblique  diameter  of  the  pelvic  brim.  In  the  left  oblique  di- 
ameter of  the  pelvic  brim  is  the  bitemporal  diameter  of  the 


Fig.  58. — The  body  born  down  to  the  shoulders,  the  right  shoulder 
pivoting  beneath  the  pubes;  the  left  upon  the  pelvic  floor. 

head.  During  the  birth  of  the  body  the  flexed  head  rotates 
from  left  to  right,  the  face  coming  upon  the  pelvic  floor,  the 
occiput  beneath  the  pubes.  As  the  body  is  raised  over  the 
mother's  abdomen  the  head  passes  over  the  pelvic  floor  with 
extreme  flexion,  the  face  being  closely  applied  to  the  pelvic 
floor  and  perineum. 


164  MANUAL   OF   OBSTETRICS 

The  Mechanism  of  Breech  Presentation,  Second  Position. 
—In  this  the  trunk  of  the  child's  body  descends  through  the 
pelvic  brim  in  the  left  oblique  diameter,  the  bistrochanteric 


Fig.  59. — Breech  presentation,  the  head  normally  in  the  pelvic  cavity, 
the  occiput  in  front. 


Fig.  60. — Breech  presentation;  normal  birth  of  the  head,  the  body 

raised. 


MECHANISM    OF    LABOR   IN    BREECH    PRESENTATION     165 


Fig.  61. — The  head  passing  out  of  the  vulva,  the  body  held  perpen- 
dicularly. 


Fig.  62. — Breech  presentation,  second  position,  the  breech  descending 
upon  the  pelvic  floor. 


166 


MANUAL    OF   OBSTETRICS 


Fig.  63. — Breech  presentation,  second  position,  the  anterior  hip  (the 
right)  beneath  the  pubes;  the  left  upon  the  pelvic  floor. 


Fig.  64. — Breech  presentation,  second  position;  the  hips  expelled  by 
strong  lateral  flexion  of  the  trunk. 


MECHANISM    OF   LABOR   IN   BREECH    PRESENTATION      167 

engaging  in  the  left  oblique  diameter  of  the  mother's  pelvic 
brim.  The  thickness  of  the  child's  body  above  the  pubes 
enters  in  the  right  oblique  diameter. 

As  the  breech  of  the  child  reaches  the  pelvic  floor  the  left 
or  anterior  hip  rotates  from  right  to  left  beneath  the  pubes 
and  the  right  or  posterior  hip  passes  over  the  pelvic  floor. 
The  shoulders  descend  in  the  pelvic  brim  in  the  left  oblique 
diameter,  the  anterior  or  right  shoulder  rotating  to  the  pubes 
and  engaging  beneath  it,  the  left  or  posterior  shoulder  then 
passes  over  the  pelvic  floor.  The  head  in  strong  flexion  passes 
through  the  brim  of  the  pelvis  with  its  bitemporal  diameter 
in  the  right  oblique,  its  suboccipito-bregmatic  in  the  left 
oblique.  As  the  head  reaches  the  pelvic  floor  in  strong  flex- 
ion the  face  gradually  appears  in  the  vulva,  the  vertex  being 
tightly  applied  beneath  the  pubes.  By  a  motion  of  extreme 
flexion  the  head  is  finally  born. 


CHAPTER  XII 

THE  PHYSIOLOGY  OF  LABOR 

THE  MATERNAL  PHYSIOLOGY  OF  LABOR 

Labor  on  the  part  of  the  mother  is  an  intensely  active 
muscular  exertion  in  which  all  of  the  voluntary  muscles  of  the 
body  are  called  into  play.  The  actual  expulsion  of  the  fetus 
is  effected  by  the  contractions  of  the  uterus,  aided  by  the 
fixation  of  the  diaphragm  and  the  contraction  of  the  abdom- 
inal muscles. 

By  virtue  of  the  anatomical  distribution  of  its  muscular 
fibres  the  uterus  contracts  symmetrically,  compressing  its 
contents  and  forcing  the  fetus  from  above  downward.  The 
enlarged  round  ligaments  of  the  uterus  contract  with  its 
expulsive  muscle,  drawing  the  uterus  forward  and  bringing 
it  into  the  axis  of  the  pelvic  brim.  The  uterine  contrac- 
tions are  rhythmical,  beginning  gradually,  reaching  their 
highest  point,  and  subsiding.  With  the  exception  of  the 
few  contractions  which  immediately  expel  the  presenting  part 
the  uterine  contractions  alternate  in  length  and  severity,  a 
vigorous  powerful  contraction  being  succeeded  by  one  much 
less  long  and  severe.  In  natural  labor  the  period  between 
uterine  contractions  is  quiescent  and  the  patient  is  free  from 
pain. 

The  first  contractions  of  the  uterus  are  comparatively  short 
in  duration  and  of  moderate  strength  only.  Their  function 
is  to  dilate  the  cervix,  and  fit  the  presenting  part  into  the 
pelvic  brim  and  cause  it  to  descend  below  the  promontory 
of  the  sacrum.  During  this,  the  first  stage  of  labor,  the 
patient  complains  of  pain  commencing  in  the  back  and  pass- 
ing on  both  sides  to  the  front  of  the  body.  The  pains  are 
said  to  be  nagging,  sharp  and  more  or  less  distressing,  caus- 
ing considerable  suffering.  In  a  healthy  woman,  if  the 
patient  be  up  and  about,  her  attention  may  be  diverted  and 

168 


THE   MATEKNAL   PHYSIOLOGY    OF    LABOR  169 

she  may  scarcely  notice  these  pains.  In  cases  where  the 
nervous  system  is  obtunded  by  drugs  or  disease  the  first 
stage  of  labor  is  often  not  perceived.  During  dilatation  of 
the  cervix  a  free  secretion  of  mucus  is  exuded  by  the  cer- 
vical glands,  which  is  blood-tinged  from  small  lacerations  in 
the  mucous  membrane.  This  discharge  is  called  in  common 
language  "the  show."  The  pains  of  the  first  stage  of  labor 
are  sometimes  not  distinguished  from  intestinal  colic,  irri- 
tability of  the  bladder,  or  neuralgic  or  rheumatic  muscular 
pain. 

The  uterus  is  roused  to  full  activity  by  the  rupture  of  the 
membranes  and  the  discharge  of  amniotic  liquid,  which  brings 
the  uterine  muscle  to  contract  directly  upon  the  fetus.  As 
uterine  contractions  increase  in  force  and  in  length,  to  steady 
the  diaphragm  the  patient  fixes  the  chest  by  grasping  some 
object  with  both  hands,  sometimes  aiding  herself  by  pressing 
her  feet  against  a  support,  closing  the  mouth,  and  pressing 
strongly  downward,  the  diaphragm  being  fixed,  thus  securing 
the  aid  of  the  abdominal  muscles  to  the  work  of  the  uterus. 
This  is  called  "bearing  down."  The  entire  muscular  system 
may  be  brought  into  activity  during  this  act,  the  muscles 
and  skin  are  filled  with  blood,  the  surface  of  the  skin  is 
reddened,  its  temperature  increased,  and  slight  moisture 
forms  upon  the  surface  of  the  body;  the  pulse  becomes 
strong  and  regular,  and  between  muscular  efforts  the  patient 
rests,  sometimes  dropping  asleep.  The  expulsive  efforts  of 
the  mother  culminate  in  very  strong  contractions  as  the  head 
is  forced  out  over  the  pelvic  floor.  Its  birth  is  followed  by  a 
short  period  of  rest  and  then  the  shoulders  are  expelled,  the 
body  readily  escaping.  A  pause  of  from  half  an  hour  to  an 
hour  then  ensues,  during  which  the  uterus  contracts  and  re- 
tracts, gradually  lessening  the  area  of  placental  attachment. 
The  placenta  gradually  leaves  the  uterine  wall  and  passes 
into  the  lower  uterine  segment  and  cervix,  where  it  is  folded 
together,  its  edge  presenting  in  the  vagina. 

The  second  stage  of  labor  ends  with  the  expulsion  of  the 
fetus,  the  third  stage  commencing  with  the  extrusion  of  the 
placenta.  This  is  accomplished  by  causing  the  patient  to 
bear  down  strongly  when  the  abdominal  muscles  press  upon 
the  uterus,  exciting  uterine  contraction  and  adding  their 


170  MANUAL   OF   OBSTETRICS 

force,  which  results  in  the  expulsion  of  the  placenta.  The 
uterus  gradually  enlarges  until  it  reaches  the  umbilicus  when 
it  undergoes  gradual  contraction,  until  finally  during  the 
puerperal  period  it  should  regain  very  nearly  its  original  di- 
mensions. 

The  action  of  the  uterine  and  other  muscles  is  under  the 
direct  control  of  the  ganglia  and  nerve  fibres  supplying  these 
muscles.  The  uterus  itself  cannot  be  made  to  contract  at 
the  will  of  the  patient,  but  its  contractions  can  be  lessened  or 
prevented  by  the  inhibitory  action  of  the  brain  and  spinal 
cord.  Thus  excessive  suffering  and  pain  may  check  uterine 
contractions  and  delay  labor,  while  the  administration  of  a 
stimulating  anesthetic,  like  ether,  may  take  the  brake  off 
from  uterine  action,  when  the  ganglia  of  the  uterine  muscle 
supply  automatic  stimulus  for  its  muscular  contraction. 

In  common  with  all  muscular  contraction,  labor  produces 
rapid  waste  in  the  muscles  and  is  dependent  for  its  success 
upon  the  normal  action  of  the  nerve  and  muscle  as  well.  It 
is  a  supreme  test  of  the  woman's  natural  powers,  but  results 
badly  in  patients  in  whom  the  muscular  and  nervous  sys- 
tems are  imperfect  and  without  coordinate  action. 

During  labor  the  heart  of  the  patient  is  taxed  to  supply 
blood  to  the  muscles.  In  normal  cases  the  heart  responds  to 
this  need  by  acting  more  strongly,  regularly  and  steadily. 
Increased  heart  action  increases  blood  pressure  and  in  many 
cases  produces  a  free  secretion  of  urine;  hence  the  common 
clinical  maxim  that  the  patient's  urinary  bladder  must  be 
emptied  regularly  and  at  short  intervals  during  prolonged 
labor.  Increased  muscular  action  calls  for  a  free  supply  of 
oxygen  to  maintain  the  normal  character  of  the  blood;  hence 
the  patient  must  be  in  a  well  aired  room  and  should  fre- 
quently breathe  deeply  and  regularly  during  the  active  stage 
of  labor.  Many  patients  complain  when  the  confinement 
room  becomes  close.  As  labor  proceeds  the  surface  of  the 
body  is  reddened,  and  its  temperature  increases  by  the  free 
circulation  of  blood  through  the  skin  and  by  muscular  action. 

When  the  birth  of  the  child  occurs  the  sudden  ending  of 
muscular  activity  causes  the  veins  to  dilate  and  the  patient 
often  complains  of  cold,  and  may  have  a  slight  rigor.  The 
perspiration  upon  the  surface  of  the  body  becomes  clammy 


PHYSIOLOGY   OF    LABOR   PERTAINING   TO    FETUS          171 

and  creates  a  feeling  of  chill.  This  is  a  temporary  phenome- 
non, and  as  the  circulation  becomes  adjusted  it  passes  away. 

Excretion  During  Labor. — Nature  usually  takes  care  of  the 
increased  waste  incident  to  labor  without  detriment  to  the 
patient.  Free  secretion  of  urine,  perspiration  and  exhalation 
through  the  lungs,  relieve  her  of  waste  material.  Unless 
the  bowel  has  been  previously  emptied  its  contents  may  be 
expelled  during  the  birth  of  the  child.  The  loss  of  water 
through  the  skin  or  in  vapor  through  the  lungs  is  consider- 
able, and  the  patient  after  the  birth  of  the  child  frequently 
complains  of  thirst. 

The  Nervous  System  During  Labor. — No  test  for  the  con- 
dition of  the  nervous  system  is  more  searching  than  that  of 
labor.  In  perfectly  sound  and  healthy  patients  labor  pro- 
ceeds quietly  without  undue  delay,  the  patient  experiencing 
only  what  would  be  normal  fatigue  by  corresponding  muscu- 
lar exertion  from  any  other  cause.  Regular  alternation  be- 
tween muscular  contraction,  with  rest,  is  an  excellent  proof 
of  a  normal  and  stable  nervous  system.  When  on  the  con- 
trary there  is  no  rest,  but  a  constant  complaint  of  pain  and 
suffering,  the  patient  is  becoming  exhausted  or  is  physiolog- 
ically unfit  for  the  strain  of  parturition.  In  extreme  cases 
the  weakness  of  the  nervous  system  becomes  manifest  after 
labor  by  attacks  of  syncope  or  shock,  often  so  severe  as  to 
be  alarming. 

The  duration  of  spontaneous  labor  varies  greatly,  and  no 
arbitrary  division  can  be  made  of  its  several  stages.  It  has 
long  been  thought  that  the  second  stage  of  labor  should  not 
last  more  than  two  hours,  yet  spontaneous  parturition  with 
living  child  is  possible  where  the  second  stage  is  greatly  short- 
ened or  considerably  prolonged  from  this  arbitrary  limit. 

The  exhaustion  of  labor  is  commonly  so  great  that  the 
patient  sleeps  so  soon  as  it  is  over.  This,  like  rest  between 
pains,  is  a  cardinal  sign  of  a  healthy  nervous  system. 

THE   PHYSIOLOGY  OF  LABOR  PERTAINING  TO  THE  FETUS 

While  the  mother's  part  in  labor  is  intensely  active,  that 
of  the  fetus  is  passive.  Before  the  membranes  rupture  it  is 
subjected  to  no  direct  pressure  and  often  shows  no  sign  of 


172  MANUAL    OF   OBSTETRICS 

stimulation  through  increased  motions.  Patients  sometimes 
say  that  the  child  is  quieter  when  labor  begins  than  it  has 
been  previously. 

After  the  rupture  of  the  membranes  some  of  the  amniotic 
liquid  which  was  before  the  head  escapes,  the  head  presses 
directly  against  the  dilating  cervix.  If  all  the  amniotic 
liquid  is  lost  the  pressure  upon  the  fetus  becomes  at  once  con- 
siderable. The  effect  of  such  pressure  is  to  interfere  some- 
what with  the  placental  circulation  and  to  cause  temporary 
and  partial  asphyxia.  In  prolonged  labor  this  becomes  so 
pronounced  that  fetal  movements  are  increased  in  rapidity 
and  strength.  Where  labor  is  unduly  continued  the  pressure 
may  become  sufficiently  great  to  bring  about  the  death  of  the 
fetus  through  asphyxia,  and  sometimes  by  hemorrhage  into 
the  fetal  body.  Almost  all  infants  are  born  somewhat  as- 
phyxiated, which  shows  how  readily  this  result  can  be  brought 
about  by  abnormal  birth  pressure.  The  birth  of  the  head 
is  often  followed  by  slight  respiratory  movements  from  the 
stimulus  of  the  external  atmosphere  upon  the  child's  face. 
The  beginning  of  respiration  will  depend  upon  the  occlusion 
of  the  umbilical  vessels  and  the  separation  of  the  placenta. 

In  impacted  labor  birth  pressure  may  be  sufficient  to  cause 
the  expulsion  of  meconium  from  the  child's  intestines  and 
sometimes  to  empty  the  bladder. 

At  birth,  if  the  umbilical  cord  be  strongly  beating  respira- 
tion may  be  delayed  for  some  minutes.  Slight  respiratory 
movements  will  result  from  the  altered  temperature  into 
which  the  child  comes  and  the  irritation  to  its  skin.  As  the 
umbilical  vessels  become  gradually  occluded  respiration  will 
normally  be  established.  The  fetal  lungs  do  not  at  once  ex- 
pand entirely,  but  sufficient  air  enters  to  maintain  the  action 
of  the  fetal  heart. 


CHAPTER  XIII 
THE  CONDUCT  OF  LABOR 

The  conduct  of  spontaneous  labor  must  follow  the  cardinal 
obstetric  signs  to  be  successful.  The  obstetrician  must  stand 
ready  to  interfere  and  to  help  if  the  natural  forces  fail.  The 
necessity  for  interference  can  only  be  perceived  by  accurate 
observation  on  the  part  of  those  who  know  the  physiology  of 
normal  labor. 

Much  of  the  success  of  spontaneous  parturition  depends 
upon  the  vigorous  condition  of  the  patient,  which  can  only  be 
secured  by  good  care  during  pregnancy.  When  this  is  pres- 
ent, and  the  obstetrician  knows  that  the  birth  canal  is  normal 
and  the  fetus  proportionate  in  size,  he  may  await  the  natural 
development  of  labor  without  concern. 

FIRST  STAGE 

During  the  first  stage  if  the  patient  is  under  intelligent  care 
his  presence  is  rarely  needed.  The  patient  should  be  pre- 
pared for  labor  by  thoroughly  emptying  the  lower  bowel  with 
a  copious  injection,  and  by  seeing  to  it  that  the  urinary  blad- 
der of  the  patient  is  frequently  emptied.  In  hospital  cases 
a  tepid  soap  and  water  bath  should  be  given  with  the  patient 
standing.  The  hair  should  be  braided  or  otherwise  ar- 
ranged conveniently,  and  the  patient  clothed  in  old  linen 
which  can  be  torn  if  necessary.  The  antiseptic  preparation 
of  the  external  parts  should  commence  by  clipping  or  shaving 
the  hair  upon  the  pubes,  followed  by  thorough  scrubbing  of 
the  external  genital  organs  with  soap  and  water.  After  this 
boiled  water  should  be  used  copiously,  and  then  a  solution  of 
bichloride  of  mercury,  1:4000,  or  lysol  one  per  cent.  A 
sterile  vulvar  dressing  should  be  retained  in  position  by  a 
T-bandage.  The  purpose  of  this  dressing  is  two-fold — to 
guard  against  the  entrance  of  septic  bacteria,  and  to  give  an 

173 


174  MANUAL   OF   OBSTETRICS 

opportunity  to  determine  the  nature  and  quantity  of  the 
vaginal  discharge. 

The  preparations  for  labor  should  not  be  too  hurried  as 
regards  the  patient,  unless  labor  is  precipitate.  It  is  desir- 
able to  divert  the  patient's  attention  as  much  as  possible 
from  the  nagging  pains  of  dilatation,  and  her  preparation 
serves  a  useful  purpose. 

During  the  first  stage  of  labor  there  will  usually  be  an  op- 
portunity to  give  the  patient  nourishment.  Such  should  be 
liquid  of  the  most  nutritious  and  digestible  character,  in 
many  cases  excluding  milk.  Small  quantities  of  nourish- 
ment given  as  frequently  as  the  stomach  will  permit,  is  best. 
Where  dilatation  of  the  cervix  is  rapid,  vomiting  may  occur, 
and  this  has  been  held  as  an  indication  of  a  short  and  speedy 
labor. 

If  the  patient  is  accustomed  to  tea  or  coffee  this  may  be 
taken  in  moderation  during  the  first  stage  of  labor. 

The  patient  should  be  encouraged  to  be  up  and  about  as 
much  as  possible  during  the  first  stage,  to  aid  in  the  descent 
of  the  presenting  part  and  to  divert  her  attention.  She 
should  be  made  as  comfortable  as  possible,  and  her  surround- 
ings should  be  as  cheerful  as  circumstances  permit. 

Should  the  first  stage  be  prolonged  the  patient  will  require 
sleep.  Efforts  should  be  made  to  procure  this  without  drugs, 
by  isolating  the  patient  for  a  short  time  in  a  well  ventilated 
and  slightly  darkened  room.  Should  this  not  be  successful, 
milder  sedatives,  such  as  bromides,  may  be  employed. 

During  the  first  stage  of  labor  a  nurse  should  prepare  the 
patient's  bed,  and  have  ready  such  dressings  and  solutions 
as  may  be  required.  A  copious  supply  of  hot  water  is  de- 
manded and  unless  the  physician  has  otherwise  ordered  he 
should  be  notified  that  labor  has  begun.  If  the  patient  lies 
down,  she  should  lie  on  the  left  side,  toward  which  the  fetal 
back  is  directed,  with  the  lower  limbs  partly  flexed.  This 
facilitates  the  descent  of  the  presenting  part  and  its  rotation. 

THE  SECOND  STAGE 

Remembering  that  dilatation  is  often  complete  before  the 
membranes  rupture,  the  attendant  should  judge  more  by  the 
character  and  severity  of  the  pains  than  by  the  rupture  of  the 


THE   SECOND    STAGE  175 

membranes,  in  determining  the  progress  of  labor.  When  ex- 
pulsive pains  begin  the  medical  attendant  should  be  sum- 
moned and  the  patient  should  be  thoroughly  examined.  As 
the  pains  increase  in  severity  the  patient's  constant  demand 
may  be  for  anesthesia  or  for  some  drug  to  mitigate  her  suffer- 
ing. It  is  unwise  to  use  anesthetics  unless  labor  is  so  far 
advanced  that  if  necessary  the  obstetrician  can  terminate  it 
immediately  by  forceps  or  version.  As  the  pains  become 
vigorous  the  patient  must  lie  down  upon  that  side  toward 
which  the  presenting  part  of  the  fetus  and  its  back  are  di- 
rected. The  patient  usually  demands  that  someone  should 
grasp  her  hand  or  rub  her  back  during  this  period.  The 
abdomen  and  the  uterus  should  not  be  massaged  under  nor- 
mal conditions. 

As  the  fetus  descends  the  uterus  will  grow  smaller  in  the 
abdomen  and  the  fundus  project  forward.  Corresponding 
with  the  alternating  character  of  the  pains  the  presenting 
part  will  advance  and  then  recede,  thus  avoiding  continuous 
pressure  upon  the  maternal  parts.  Where  this  phenomenon 
of  alternating  advance  and  recession  are  absent,  the  condi- 
tion becomes  pathological  and  may  demand  active  interfer- 
ence. The  attendant  should  take  care  that  the  patient's 
urinary  bladder  is  thoroughly  and  frequently  emptied  during 
the  second  stage  of  labor.  When  the  head  reaches  the  pel- 
vic floor  the  use  of  ether  well  diluted  with  air  is  indicated, 
and  this  should  preferably  be  administered  by  an  experi- 
enced physician.  Ether  should  only  be  given  during  the 
most  severe  pains  and  should  not  be  commenced  until  con- 
siderable dilatation  is  present.  By  using  ether  at  the  summit 
of  a  pain  the  patient's  suffering  is  lessened  without  checking 
the  progress  of  labor.  During  the  intervals  of  rest  care 
should  be  taken  that  the  patient  be  not  disturbed.  She 
should  not  be  spoken  to,  the  room  should  be  absolutely  quiet, 
and  an  effort  made  to  induce  a  few  moments  of  natural  sleep. 

As  the  moment  of  expulsion  approaches  the  obstetrician 
must  decide  what  he  will  do  to  prevent  laceration  of  the 
perineum  and  pelvic  floor.  Unless  his  methods  be  wisely 
chosen  and  properly  carried  out  it  would  be  better  for  his 
patient  if  he  did  nothing.  It  must  be  remembered  that  the 
most  important  portion  of  the  pelvic  floor  is  the  levator  ani 


176 


MANUAL   OF    OBSTETRICS 


muscle  whose  anterior  border  marks  the  anterior  limit  of  the 
pelvic  floor.  The  posterior  vaginal  wall  and  the  fourchette 
are  composed  of  elastic  tissue  which  will  readily  tear  and 
whose  integrity  is  not  indispensable  for  the  patient's  health. 
In  fact,  a  tear  through  this  tissue  to  the  edge  of  the  muscle, 
provided  it  be  clean  cut  and  in  the  centre  line,  is  not  of  pri- 
mary importance.  If,  however,  the  fascia  which  attaches 
the  levator  ani  muscle  in  its  various  branches  to  the  pelvis 
be  injured,  prolapse  of  the  genital  organs  will  surely  develop. 


Fig.  65. — Protection  of  the  pelvic  floor;  spontaneous  birth,  the  patient 
in  the  left  lateral  position. 


Whatever  method  of  protecting  the  perineum  and  pelvic 
floor  be  employed  it  must  be  such  as  not  to  hinder  the  exit  of 
the  head  and  to  permit,  if  necessary,  laceration  in  the  centre 
line  of  the  soft  tissues.  On  the  other  hand,  the  head  should  be 
directed  moderately  forward  toward  the  pubes  to  prevent  the 
exercise  of  undue  force  upon  the  perineum  and  the  pelvic 
floor.  The  rate  at  which  the  head  passes  out  of  the  mother's 
body  is  important,  as  very  sudden  and  violent  birth  may  pro- 


THE   SECOND    STAGE 


177 


duce  serious  laceration.  To  accomplish  this,  the  patient 
lying  upon  the  left  side,  a  folded  pillow  covered  with  a  sterile 
towel  or  a  roll  covered  with  sterile  material,  should  be  placed 
between  the  knees.  This  will  permit  the  obstetrician  to  do 
what  is  necessary  in  controlling  the  birth  of  the  head. 

Standing  or  sitting  with  his  face  toward  the  feet  of  the 
patient  the  obstetrician  passes  the  left  hand  between  the 
patient's  thighs,  resting  the  curved  fingers  upon  the  vertex 


Fig.  66. — Holding  back  the  head  in  spontaneous  labor  when  sudden 
expulsion  is  threatened. 


of  the  child's  head  as  it  emerges.  With  this  hand  the  rate  of 
exit  may  be  controlled  and  the  occiput  carried  gently  upward. 
Should  a  violent  pain  threaten  to  force  the  head  out  suddenly 
the  left  hand  should  be  placed  over  the  head,  and  over  this 
the  right  hand,  and  strong  traction  be  made  upward  and 
backward.  To  protect  the  pelvic  floor  and  perineum  gauze 
or  sterile  linen  wet  with  bichloride  solution  1 : 4000,  may  be 
taken  in  the  palm  of  the  obstetrician's  right  hand,  and  the 
hand  placed  over  the  anus.  This  should  not  extend  suffi- 


178  MANUAL   OF   OBSTETRICS 

ciently  high  to  prevent  the  obstetrician  from  seeing  the 
posterior  wall  of  the  vagina  and  the  entire  skin  perineum. 
With  the  right  hand,  as  the  head  comes  down,  moderate 
pressure  may  be  made  upon  the  pelvic  floor  upward  and 
backward,  and  the  head  gently  but  steadily  directed  upward 
toward  the  pubes.  As  the  head  comes  further  in  the  vulva 
it  may  be  held  by  the  left  hand,  while  the  right  hand  may 
carry  the  distended  pelvic  floor  and  perineum  backward 


Fig.  67. — Delivering  the  head  under  the  control  of  the  obstetrician, 
between  the  hands. 

toward  the  mother's  coccyx.  In  this  way  the  parts  are 
stretched  naturally  and  without  undue  violence  or  trauma- 
tism. 

When  it  is  evident  that  the  pelvic  floor  can  readily  be 
stripped  backward  over  the  head  and  face,  the  left  hand 
should  hold  the  vertex  gently  but  firmly  up  beneath  the  pubes, 
while  the  right  hand  should  retract  the  pelvic  floor  and 
perineum  over  the  child's  face. 

During  this  time  the  patient  requires  rapid  anesthesia, 


THE   SECOND    STAGE 


179 


sufficient  to  make  her  completely  unconscious  for  the  moment. 
This  can  be  readily  done  by  skilful  administration,  and 
patients  often  assert  that  they  can  hear  voices  and  sounds, 
although  they  had  no  sensation.  This  brief  but  efficient 
anesthesia  is  sometimes  called  obstetric  anesthesia,  and  is 
dependent  upon  the  skilful  use  of  small  quantities  of  ether 
well  diluted  with  air,  and  also  upon  the  condition  of  the  pa- 


Fig.  68. — Delivering  the  posterior  shoulder. 

tient  herself.  Rapid  breathing  in  a  parturient  woman  fre- 
quently causes  a  condition  of  temporary  anesthesia,  which 
may  sometimes  be  utilized. 

The  interval  occurring  between  the  expulsion  of  the  head 
and  the  shoulders  should  be  utilized  by  the  attendant  in  thor- 
oughly but  gently  wiping  the  region  of  the  child's  eyes  with 
soft  sterile  linen  dipped  in  boric  acid  solution.  The  mouth 


180 


MANUAL   OF    OBSTETRICS 


Fig.  69. — liaising  the  posterior  shoulder  over  the   pelvic   floor   and 

perineum. 


Fig.  70. — Drawing  down  the  anterior  shoulder  beneath  the  pubes. 


THE   SECOND    STAGE  181 

should  also  be  cleansed,  and  care  taken  not  to  wound  the 
mucous  membrane  of  the  mouth. 

After  a  varying  interval  expulsive  efforts  should  again 
begin  and  the  shoulders  be  born,  followed  by  the  rapid  pass- 
ing of  the  remainder  of  the  body.  The  child  should  imme- 
diately be  placed  upon  its  right  side  and  in  such  a  position  that 
it  will  not  inspire  blood  or  amniotic  liquid  which  the  mother 


Fig.  71. — Drawing  down  the  anterior  shoulder  beneath  the  pubes. 

has  just  ejected.  The  cord  should  be  taken  between  the 
thumb  and  finger  to  feel  its  pulsations  and  should  not  be 
tied  and  cut  until  it  has  ceased  to  beat.  Observation  shows 
that  this  delay  gains  for  the  child  several  ounces  of  blood. 
During  this  time  the  assistant  should  place  the  hand  upon 
the  uterus  and  make  steady  but  gentle  pressure,  carrying  the 
fundus  towards  the  symphysis  pubis. 


182 


MANUAL   OF   OBSTETRICS 


THIRD  STAGE 

When  the  cord  has  been  tied  and  cut,  and  the  child  has 
been  removed,  the  patient  practically  enters  upon  the  third 
stage  of  labor.  Too  much  importance  cannot  be  ascribed  to 
the  necessity  for  giving  the  patient  a  period  of  complete  rest 
after  the  birth  of  the  child,  varying  from  twenty  to  forty 
minutes.  The  patient's  head  should  be  low,  and  if  she  feels 
chilly  she  should  be  warmly  covered.  She  had  better  lie 
upon  the  back,  and  one  hand  should  be  placed  upon  the 
uterus,  not  making  strong  pressure  but  gently  carrying  the 


Fig.  72. — The  placenta  separated  and  forced  downward. 


fundus  toward  the  symphysis  pubis.  The  uterus  will  be 
felt  to  grow  gradually  smaller  as  the  placenta  separates  and 
passes  downward  into  the  cervix.  It  may  also  be  observed 
that  the  umbilical  cord  elongates.  During  this  time  many 
obstetricians  give  the  patient  one  or  two  drachms  of  fluid 
extract  of  ergot;  others  give  strychnia  hypodermatically  or 
by  the  mouth.  When  the  patient  again  complains  of  pain 
the  uterus  should  be  grasped  between  the  thumb  and  the 
four  fingers  placed  straight  behind  it,  carried  strongly  over 
the  pubes,  and  pressure  made  downward  and  backward. 


THE    PREVENTION    OF   LACERATION 


183 


The  patient  should  be  asked  to  close  the  mouth  and  to  bear 
down  at  the  same  time.  Ordinarily  the  placenta  will  emerge 
in  the  vulva  folded  together.  If  it  be  grasped  in  the  hand  of 
the  obstetrician  and  rotated,  the  membranes  twisted  into  a 
cord  will  gradually  emerge.  The  passage  of  the  placenta 
completes  labor  and  the  patient 
enters  upon  the  puerperal  state. 
So  soon  as  the  uterus  is  empty 
stimulants  should  be  given  in 
proportion  to  the  patient's  need. 
Strychnia  hypodermatically, 
with  or  without  atropin  and 
digitalin,  are  required  if  the  pa- 
tient shows  signs  of  exhaustion. 
If  the  stomach  is  irritable,  some 
preparation  of  ergot  suitable  for 
hypodermatic  use  may  be  given. 
The  condition  of  the  uterus 
should  be  ascertained  by  the 
hand,  and  the  womb  virtually 
held  in  the  hand  until  firm  and 
permanent  contraction  is  se- 
cured. 

Many  obstetricians  prefer  to 
turn  the  patient  across  the  bed 
to  secure  the  expulsion  of  the 
placenta.    This  gives  better  vi- 
sion and  permits  a  more  accurate  examination  to  determine 
the  presence  or  absence  of  lacerations.     If  the  patient  is 
exhausted,  or  the  room  be  cold,  it  is  best  to  allow  her  to  lie 
upon  her  back  and  not  to  place  her  across  the  bed. 


Fig.  73. — The  placenta  in 
the  lower  segment  and  cervix 
preceding  expulsion. 


THE  PREVENTION  OF  LACERATION 

A  moderate  laceration  of  the  genital  tract  is  inevitable  in 
spontaneous  labor  in  three-fourths  of  all  primiparous  patients. 
In  proportion  as  the  mother's  birth  canal  is  rigid,  or  the  tis- 
sues are  deficient  in  firmness  and  normal  strength,  or  the 
child's  head  is  excessively  large  or  firm,  laceration  increases 
in  extent  and  severity.  If  the  mother  delivers  herself,  is 


184  MANUAL   OF    OBSTETRICS 

uncontrolled,  and  without  anesthesia,  laceration  is  more  fre- 
quent and  extensive.  If  the  obstetrician  makes  improper 
pressure  upon  the  pelvic  floor  and  perineum,  not  allowing  the 
soft  parts  to  dilate,  he  may  force  the  head  up  against  the 
pubes  and  cause  severe  laceration  of  the  anterior  segment  of 
the  pelvic  floor.  The  obstetrician  should  never  deny  the 
possibility  of  the  occurrence  of  laceration,  nor  should  he 
boast  that  he  can  always  prevent  it.  Every  reasonable  pre- 
caution, however,  should  be  taken,  and  immediate  attention 
given  to  the  injury  whenever  circumstances  permit. 

One  of  the  most  important  factors  in  preventing  lacera- 
tion is  the  skilful  use  of  ether  during  labor.  As  every  pre- 
caution is  to  be  taken,  this  must  be  given  by  a  skilled  anes- 
thetizer.  By  using  moderate  quantities  of  ether  well  di- 
luted with  air  at  the  moment  when  uterine  contractions  are 
most  pronounced,  and  by  quickly  anesthetizing  the  patient 
when  the  head  and  shoulders  pass,  extensive  lacerations  may 
be  prevented,  and  the  number  and  severity  of  lacerations 
greatly  lessened. 

If,  however,  ether  be  administered  copiously  and  upon  the 
slightest  complaint,  the  patient's  labor  will  be  unduly  pro- 
longed, uterine  contractions  weakened,  and  assistance  often 
be  made  necessary. 

In  the  conduct  of  labor  much  can  be  done  for  the  comfort 
and  encouragement  of  the  patient  by  the  mental  attitude  of 
the  physician  and  nurse.  While  it  is  unwise  to  sympathize 
unduly  with  suffering,  still  the  patient  must  be  treated  with 
every  kindness  and  consideration  and  always  in  a  hopeful 
and  encouraging  manner.  As  little  as  possible  should  be  said 
and  whatever  possible  should  be  done,  especial  care  being 
taken  to  not  disturb  the  patient  if  she  shows  a  disposition  to 
rest.  It  is  better  to  have  no  one  in  the  confinement  room 
except  the  physician  and  nurse,  but  if  the  patient  insists 
upon  the  presence  of  someone  else,  that  person  must  take  the 
cue  of  conduct  from  the  medical  attendant.  A  relative  who 
is  excited  and  solicitous  may  often  considerably  delay  partu- 
rition and  greatly  interfere  with  the  patient's  medical  care. 
It  is  often  thought  that  spontaneous  parturition  is  a  per- 
fectly natural  process,  requiring  no  especial  attention,  but 
severe  laceration  and  injury  may  happen,  the  child's  life  and 


THE    I'KKVKNTION    OF    LACERATION  185 

that  of  the  mother  be  brought  suddenly  in  danger,  while  the 
risks  of  hemorrhage  ami  infection  in  spontaneous  labor  are 
by  no  means  small.  Much  ill-health  among  women  arises 
from  the  neglect  of  spontaneous  parturition,  and  if  one  would 
be  successful  in  obstetric  practice  he  must  give  to  spontaneous 
labor  the  same  thorough  care  and  attention  that  he  would 
bestow  upon  a  surgical  operation.  Only  such  care  has  re- 
duced the  mortality  and  morbidity  of  spontaneous  birth, 
which  was  formerly  considerable. 


CHAPTER  XIV 
THE  PATHOLOGY  OF  LABOR 

ABNORMALITIES  IN  THE  MECHANISM  OF  LABOR 
POSTERIOR  ROTATION  OF  THE  OCCIPUT 

In  spontaneous  labor  the  anterior  rotation  of  the  occiput 
depends  upon  the  normal  relation  between  the  fetus  and  pel- 
yis,  flexion  of  the  fetal  head,  normal  expulsive  forces  in  the 
uterus  and  abdominal  muscles,  and  the  normal  resisting 
power  of  the  pelvic  floor.  If  any  of  these  factors  are  entirely 
wanting,  or  in  several  of  them  are  deficient,  the  occiput  may 
turn  posteriorly.  The  most  frequent  backward  turning  of 
the  occiput  is  toward  the  right,  in  right  occipito-posterior. 
At  the  beginning  of  labor  the  head  may  be  transversely  at  the 
pelvic  brim.  If  the  pelvis  be  somewhat  larger  than  the  head 
the  latter  may  descend  transversely  through  the  pelvic  brim 
and  come  upon  the  pelvic  floor  transversely.  If  flexion  be  not 
perfect  the  head  may  become  firmly  fixed  upon  the  pelvic  floor 
in  a  transverse  position,  and  if  the  elasticity  and  muscular 
strength  of  the  pelvic  floor  are  lacking,  the  head  may  grad- 
ually sag  backward  until  it  stands  obliquely  with  the  occiput 
behind,  or  completely  with  the  occiput  under  the  promontory 
of  the  sacrum.  A  similar  process,  with  reversed  direction  of 
movement,  may  be  the  case  when  the  occiput  starts  with  the 
fetal  back  directed  toward  the  left  side  and  rotates  from  the 
left  posteriorly. 

Diagnosis. — The  diagnosis  of  posterior  rotation  of  the  oc- 
ciput is  usually  made  by  vaginal  examination.  Occasionally 
where  the  mother's  tissues  are  thin  the  head  can  be  palpated 
in  a  transverse  position  as  it  enters  the  pelvis.  As  the  back 
follows  the  head  in  rotation,  palpation  might  detect  the  back 
as  turning  behind  when  the  head  rotates  posteriorly  in  the 
pelvis.  The  heart  sounds  would  also  be  heard  posteriorly 

186 


POSTERIOR   ROTATION   OF   THE    OCCIPUT 


187 


unless  rotation  was  completely  behind,  when  they  might 
be  heard  through  the  child's  chest  in  nearly  the  usual  posi- 
tion. 

By  vaginal  examination,  while  the  head  stands  transversely 
the  sagittal  suture  is  found  extending  transversely.  At  one 
of  its  extremities  is  the  anterior  and  at  the  other  the  poste- 
rior fontanelle.  It  is  rare  to  find  both  of  these  available  to 
touch,  but  usually  the  posterior  can  be  detected.  As  poste- 


Fig.  74. — Second  position,  vertex  presentation,  from  which  abnormal 
rotation  is  most  apt  to  develop. 

rior  rotation  occurs  the  occiput  is  found  to  recede  from  the 
pubes  and  the  anterior  fontanelle  can  be  made  out  behind  the 
pubes.  If  there  be  considerable  pressure  the  posterior  fon- 
tanelle is  obliterated  and  only  the  meeting  place  of  three  bony 
lines  remains. 

Clinical  History  of  Labor. — In  posterior  rotation  of  the 
occiput  labor  is  usually  longer,  more  painful  and  more  ex- 
hausting than  normal.  As  the  occiput  turns  behind  it  presses 


188  MANUAL    OF    OBSTETRICS 

against  the  pelvic  floor  and  the  coccyx  and  sacrum,  and  may 
press  heavily  upon  nerve  trunks  at  the  side  of  the  pelvis. 
When  posterior  rotation  is  complete  exhaustion  often  super- 
venes and  spontaneous  labor  stops.  The  risk  to  the  mother 
arises  from  exhaustion,  and  the  dangers  of  infection  occur 


Fig.   75. — Second  position,   vertex  presentation;   the  vertex  rotating 

posteriorly. 


in  any  labor  which  is  prolonged  and  in  which  repeated  vag- 
inal examination  and  instrumental  delivery  are  practised. 
The  child  is  exposed  to  greater  danger  through  the  risks  of 
inspiration  pneumonia  and  the  dangers  of  difficult  forceps 
extraction.  Lacerations  inevitably  occur  unless  the  vertex 
can  be  rotated  anteriorly  by  artificial  means. 


POSTERIOR   ROTATION    OF   THE    OCCIPUT  189 

Prophylactic  Treatment. — In  all  cases  of  labor  an  accurate 
diagnosis  as  early  as  possible  during  labor  should  be  made. 
If  the  occiput  is  transverse  or  is  beginning  to  rotate  poste- 
riorly the  mother  should  be  placed  upon  that  side  toward 
which  the  back  is  directed.  The  membranes  in  primiparous 
patients  should  be  preserved  as  long  as  possible,  and  in  multi- 
parous  patients  until  dilatation  is  three-fourths  completed. 


Fig.  76. — The  head  impacted,  the  occiput  posterior. 


If  exhaustion  threatens  strychnia  should  be  given  to  the 
mother,  the  urinary  bladder  emptied  frequently,  and  the 
lower  bowel  kept  empty.  If  good  muscular  action  can  be 
procured  the  occiput  may  still  rotate  anteriorly  without  inter- 
ference. In  some  cases  flexing  the  thighs  upon  the  pelvis 
seems  to  further  rotation. 


190  MANUAL   OF   OBSTETRICS 

Active  Treatment. — When  the  occiput  shows  a  tendency 
to  turn  behind  and  the  head  is  only  in  the  pelvic  brim,  some 
obstetricians  prefer  to  complete  dilatation  under  ether  and 
by  the  hand  perform  podalic  version  and  delivery. 

When  the  head  has  reached  the  pelvic  cavity  with  begin- 
ning posterior  rotation,  and  efforts  to  secure  anterior  turning 
by  posture  and  stimulation  have  failed,  the  operator  may 
prefer  to  rotate  the  head  before  it  has  become  impacted  upon 
the  pelvic  floor  and  then  allow  spontaneous  expulsion  to  fol- 
low. To  accomplish  this  the  patient  must  be  anesthetized 
with  ether  or  chloroform,  placed  upon  her  back  at  the  edge 
of  a  table  or  bed,  the  bladder  completely  emptied  by  catheter, 
and  under  antiseptic  precautions  the  gloved  hand  should  be 
introduced  and  an  effort  made  to  rotate  the  occiput  in  front 
of  the  median  line  of  the  pelvis.  If  the  back  is  to  the  left  the 
rotation  must  be  on  the  left  side  anteriorly;  if  the  back  is 
toward  the  right  the  rotation  must  be  on  the  right  side  an- 
teriorly. The  hand  may  be  retained  within  the  cervix  dur- 
ing several  uterine  contractions,  which  may  be  stimulated  by 
uterine  massage.  If  the  head  can  be  brought  to  turn  through 
two-thirds  of  the  pelvic  circumference  toward  the  front,  the 
forceps  may  then  be  applied  obliquely  to  the  head,  and  with 
intermittent  traction  the  head  brought  down  firmly  upon  the 
pelvic  floor  with  the  occiput  beneath  the  pubes.  It  should 
be  retained  in  that  position  during  one  or  two  uterine  con- 
tractions when,  if  the  operator  prefers,  the  forceps  may  be  re- 
moved and  the  head  expelled  by  the  unaided  forces  of  labor. 
Many  prefer,  however,  to  compel  delivery  without  removing 
the  forceps  or  without  waiting  for  spontaneous  efforts. 

If  the  occiput  has  turned  completely  behind  and  posture 
and  stimulation  have  failed  to  secure  rotation,  and  the  effort 
to  turn  the  occiput  anteriorly  with  the  hand  is  unsuccessful, 
the  obstetrician  must  choose  between  delivery  by  forceps 
with  the  occiput  behind  or  craniotomy.  The  latter  is  rarely 
required,  and  with  suitable  axis  traction  forceps  the  head  can 
usually  be  delivered. 

The  method  of  such  delivery  consists  in  applying  axis  trac- 
tion forceps  accurately  to  the  sides  of  the  head  and  making 
intermittent  tractions  until  the  forehead  of  the  child  en- 
gages beneath  the  pubes.  The  grasp  of  the  forceps  is  then 


PRESENTATION   OF   THE   PARIETAL   BONE  191 

relaxed,  the  handles  are  lowered  and  the  cephalic  portions  of 
the  blades  given  a  new  grasp  upon  the  head  in  such  a  man- 
ner as  to  enable  the  operator  to  lift  the  occiput  by  flexion 
over  the  pelvic  floor.  Considerable  laceration  is  inevitable 
in  such  a  delivery  in  both  the  anterior  and  posterior  segments. 
With  proper  forceps,  complete  anesthesia  and  skilful  manipu- 
lation, the  lacerations  should  not  extend  into  the  bowel,  but 
will  usually  complete  the  tear  of  the  perineum,  and  lacerate 
in  varying  degree  the  fascias  of  the  pelvic  floor.  The  an- 
terior segment  will  be  more  or  less  injured.  In  our  experi- 
ence, the  Simpson  forceps  with  tapes  for  axis  traction,  which 
are  applied  to  the  blades  opposite  the  centre  of  the  fetal  head, 
are  most  efficient  in  these  cases.  They  cause  complete 
flexion,  admit  of  ready  change  of  the  grasp  of  the  instru- 
ment, and  often  succeed  where  more  complicated  instruments 
do  not. 

If  craniotomy  becomes  necessary,  cranioclasis  should  be 
performed,  and  if  necessary  the  size  of  the  head  lessened  by 
the  cephalotribe. 

PRESENTATION  OF  THE  PARIETAL  BONE 

In  this  abnormality  the  head  presents  at  the  pelvic  brim, 
flexion  fails,  the  head  turns  transversely  and  lodges  at  the 
brim  of  the  pelvis,  strong  lateral  flexion  of  the  head  develop- 
ing. This  brings  one  of  the  parietal  bones  to  present  in  the 
pelvic  brim.  The  occiput  and  chin  are  strongly  forced 
against  the  sides  of  the  pelvis,  the  head  becomes  impacted, 
and  spontaneous  delivery  is  impossible.  Disproportion  be- 
tween mother  and  child  is  the  most  frequent  cause  of  this 
abnormality. 

Diagnosis.— The  parietal  bone  is  not  infrequently  mistaken 
for  the  occiput.  As  the  scalp  over  the  occiput  may  be  some- 
wrhat  swollen  in  labor  it  may  be  difficult  to  recognize  its 
sutures  and  fontanelle.  The  boss  of  the  parietal  bone  may 
feel  to  the  finger  like  the  swollen  occiput.  Usually  the 
sagittal  or  occipital  sutures  can  be  made  out  in  occipital 
presentation,  while  in  parietal  presentation  it  is  not  always 
possible  to  distinguish  the  fronto-parietal  sutures.  If 
sufficient  of  the  hand  be  introduced  to  palpate  the  head,  if 
necessary  under  anesthesia,  the  diagnosis  becomes  clear. 


192 


MANUAL    OF    OBSTETRICS 


The  Clinical  Course  of  Labor.— Spontaneous  labor  is  im- 
possible in  this  condition.  Repeated  contractions  of  the 
uterus  and  abdominal  muscles  force  the  head  more  firmly  into 
the  brim  in  its  vicious  position.  The  bladder  may  become 
enormously  distended  as  the  head  may  press  upon  the  neck 
of  the  bladder  and  urethra.  If  assistance  be  not  given  the 
child  will  perish  from  birth  pressure,  and  the  mother  be  ex- 
posed to  the  danger  of  exhaustion  and  septic  infection. 


Fig.  77. — Parietal  hone  presentation. 

Prophylactic  Treatment. — The  general  rule  to  put  the 
mother  on  the  side  toward  which  the  back  of  the  child  is  di- 
rected may  be  of  service  in  preventing  the  development  of 
this  complication.  Unless  flexion  be  secured,  good  uterine 
contractions  are  of  no  avail  but  only  wedge  the  head  more 
tightly  into  the  pelvic  brim.  Rupture  of  the  uterus  may  be 
threatened  when  uterine  contractions  are  strong  and  tetanic. 

Active  Treatment. — To  save  the  life  of  the  child  and  to 
spare  the  mother  prolonged  suffering  and  the  risk  of  uterine 


BROW    PRESENTATION 


193 


rupture  or  septic  infection,  delivery  must  be  accomplished  so 
soon  as  the  vicious  position  is  clearly  made  out.  Where  hos- 
pital facilities  are  available  delivery  by  abdominal  section  is 
indicated,  if  the  child  be  living  and  in  reasonably  good  condi- 
tion. If  the  patient  cannot  have  hospital  advantages  she 
must  be  treated  in  her  home.  Under  surgical  anesthesia  an 
attempt  may  be  made  to  cautiously  relax  the  uterus  and  per- 
form internal  podalic  version.  Should  this  fail  craniotomy 
is  indicated. 

BROW  PRESENTATION 

Where  instead  of  flexion  partial  extension  develops,  the 
brow  or  forehead  of  the  fetus  presents.     This  brings  the 


Fig.  78. — The  fetal  head  in  brow  presentation. 

occipito-mental  or  maximum  diameter  of  the  fetal  head  in  re- 
lation with  the  obliques  of  the  pelvic  brim,  when  descent  and 
rotation  become  impossible.  Impaction,  fetal  death,  and 
maternal  exhaustion  and  infection  may  result  unless  artificial 
help  be  given.  The  causes  of  the  condition  are  disproportion 


194  MANUAL   OF   OBSTETRICS 

between  mother  and  child,  premature  escape  of  the  amniotic 
liquid,  and  failure  of  flexion  to  develop. 

Diagnosis. — By  palpation  the  diagnosis  is  rarely  possible 
except  where  the  tissues  are  unusually  thin.  If  a  deep  groove 
or  depression  can  be  made  out  between  the  occiput  and  the 
back  or  shoulder,  it  may  be  inferred  that  normal  flexion  is 
lacking.  By  vaginal  examination  the  forehead  can  be  made 
out,  the  superciliary  ridges,  and  sometimes  the  orbits,  and 
in  some  cases  the  frontal  suture.  The  orbits  and  beginning 
of  the  face  can  often  be  felt  and  help  to  distinguish  between 
brow  and  vertex  presentation. 

Prophylactic  Treatment. — The  retention  of  the  membranes 
in  primiparous  patients  until  they  rupture  spontaneously,  and 
in  multiparous  patients  until  dilatation  is  three-fourths  ad- 
vanced, is  indicated.  Posture  is  also  of  value,  and  care  must 
be  taken  that  the  urinary  bladder  of  the  mother  is  emptied 
sufficiently  often. 

Active  Treatment.— Under  chloroform  and  with  antiseptic 
precautions,  if  the  uterus  be  not  tightly  contracted,  a  cau- 
tious effort  may  be  made  to  convert  the  brow  into  a  vertex 
presentation.  Should  this  fail  and  the  uterus  relax  under 
anesthesia,  the  operator  may  elect  podalic  version  if  he  is 
confident  that  the  lower  uterine  segment  is  not  unduly  dis- 
tended. Where  hospital  facilities  are  available,  and  the  child 
is  in  good  condition,  delivery  by  abdominal  section  will  give 
the  best  results  for  mother  and  child.  In  neglected  and  im- 
pacted cases,  with  a  dead  fetus,  craniotomy  may  be  per- 
formed. 

POSTERIOR  ROTATION  OF  THE  CHIN 

When  in  face  presentation,  instead  of  turning  to  t(he  front 
beneath  the  pubes,  the  chin  rotates  behind  into  the  hollow 
of  the  sacrum,  impaction  of  the  head  and  cessation  of  labor 
result.  Efforts  at  expulsion  cause  the  occiput  and  the  thick- 
ness of  the  fetal  body  at  the  neck  to  become  wedged  into  the 
pelvic  brim.  Rotation  is  impossible,  and  if  the  lower  uterine 
segment  becomes  greatly  over-distended  rupture  of  the 
uterus  may  result.  Fetal  death  is  a  common  occurrence. 

Diagnosis. — The  diagnosis  is  made  by  recognizing  the  face 
of  the  child  in  the  centre  of  the  pelvic  cavity,  the  forehead  in 


TRANSVERSE   POSITION   OF   THE   HEAD  195 

front,  the  chin  beneath  the  promontory  of  the  sacrum  and 
often  wedged  firmly  upon  the  pelvic  floor.  Labor  is  pro- 
longed and  painful  and  finally  ends  unsuccessfully  in  ex- 
haustion. 

Prophylactic  treatment  by  posture  and  stimulation  with 
retention  of  the  membranes  are  unquestionably  of  value  and 
should  be  employed  in  all  cases  of  abnormal  presentation  of 
the  presenting  part. 

Active  Treatment. — In  these  cases  efforts  to  dislodge  the 
chin  and  force  it  upward  are  exceedingly  dangerous  because 
of  threatened  rupture  of  the  uterus.  As  the  fetus  is  sub- 
jected to  considerable  pressure  under  unfavorable  circum- 
stances, fetal  death  usually  happens  early  in  labor.  Crani- 
otomy  then  becomes  the  operation  of  election,  cranioclasis 
being  usually  employed. 

TRANSVERSE  POSITION  OF  THE  HEAD 

The  condition  which  threatens  serious  complications  for 
mother  and  child,  but  which  is  often  susceptible  of  correction, 
is  that  of  transverse  position  of  the  head  at  the  time  of  engage- 
ment. This  usually  happens  where  the  head  is  of  ample 
proportions,  but  where  for  some  reason  which  may  not  be 
apparent,  rotation  does  not  develop  at  the  usual  time  in 
labor. 

Diagnosis. — Before  engagement  examination  may  show 
the  occiput  to  one  side,  the  face  on  the  other,  with  the  sagit- 
tal suture  extending  transversely.  The  rounded  occiput 
will  be  found  missing  and  also  the  irregularities  of  the  face. 

Clinical  History. — If  the  pelvis  be  ample,  and  uterine  con- 
tractions are  vigorous  the  head  may  descend  in  a  transverse 
position  to  the  pelvic  floor.  Here  its  anterior  rotation  will 
depend  largely  upon  the  normal  resistance  of  the  pelvic  floor 
and  the  contractions  of  the  uterine  and  abdominal  muscles. 

Prophylactic  Treatment. — To  secure  anterior  rotation, 
posture,  stimulation,  and  frequent  emptying  of  the  urinary 
bladder  and  of  the  bowel,  should  all  be  thoroughly  carried 
out.  In  the  majority  of  cases  anterior  rotation  develops. 
Where  it  fails  patients  should  be  anesthetized  and  under 
antiseptic  precautions  the  gloved  hand  inserted  and  the 


190 


MANUAL   OF   OBSTETRICS 


Fig.  79. — The  floating  head  transverse  at  the  pelvic  brim. 


Fig.  80. — The  head  in  transverse  position  on  the  pelvic  floor;  fetus  in 
first  position  (Liepmann). 


TRANSVERSE    POSITION    OF    THE    FETTS  197 

ctTort  made  to  turn  the  occiput  in  front.  The  forceps  should 
be  in  readiness,  so  that  if  this  effort  is  successful,  and  the 
occiput  be  turned  in  front  of  the  median  line  of  the  pelvis 
the  forceps  may  be  applied  and  the  head  brought  upon  the 
pelvic  floor  with  the  occiput  anterior.  This  effort  is  usually 
successful  and  delivery  may  be  terminated  by  forceps. 
Should  this  fail  and  the  head  become  impacted  craniotomy 
may  be  performed.  Section  is  rarely  indicated,  because  until 
the  methods  for  vaginal  delivery  are  tried  it  may  never  be 
known  that  such  will  not  be  successful.  Efforts  to  deliver 
through  the  vagina  forbid  the  subsequent  performance  of 
Cesarean  section  through  the  danger  of  infection. 

THE   TRANSVERSE   POSITION   OF   THE   FETUS:     SHOULDER 
PRESENTATION 

This  abnormality  most  frequently  develops  in  labors 
which  begin  as  vertex  presentations,  where  for  some  reason 
the  vertex  fails  to  descend  and  lodges  at  the  side  of  the 
pelvis,  while  under  strong  expulsive  forces  the  trunk  of  the 
fetus  is  bent  laterally,  the  shoulder  presents  at  the  pelvic 
brim,  and  the  arm  may  prolapse  through  the  cervix  into  the 
vagina.  The  most  usual  of  these  conditions  is  presentation 
of  the  right  shoulder  with  the  back  in  front,  the  head  upon 
the  left  side  of  the  mother,  and  the  breech  obliquely  upon  her 
right.  Unless  the  child  be  very  small  and  the  pelvis  very 
large,  or  the  child  be  dead  and  macerated,  spontaneous  de- 
livery under  these  circumstances  is  impossible.  The  fetus 
will  perish  from  birth  pressure  and  rupture  of  the  uterus  is 
especially  threatening,  because  the  lower  uterine  segment  is 
distended  by  the  head  and  the  body  of  the  fetus. 

Diagnosis. — By  palpation  under  favorable  circumstances 
the  head  can  be  made  out  at  the  side  of  the  pelvic  brim,  the 
body  extending  across  above  the  pubes.  Heart  sounds  are 
heard  in  the  centre  of  the  abdomen  just  above  the  pubes. 

By  vaginal  examination  the  head  is  missing  in  the  pelvic 
cavity.  By  carrying  the  fingers  as  high  up  as  possible  the 
axilla  and  the  ribs  can  be  made  out,  and  the  arm  also,  if  pro- 
lapsed. Occasionally  the  fingers  can  be  carried  upon  the 
fetal  neck.  To  determine  which  arm  is  prolapsed  it  should 
be  turned  in  the  normal  position,  with  the  thumb  upwards, 


198  MANUAL   OF   OBSTETRICS 

when  it  will  correspond  with  one  hand  of  the  obstetrician. 
If  it  be  with  the  right  hand  of  the  obstetrician,  it  is  the  right 
fetal  hand,  and  conversely. 

The  Clinical  Course  of  Labor. — This  condition  is  especially 
dangerous  because  of  threatened  uterine  rupture  and  be- 
cause the  prolapsed  condition  of  the  hand  which  often  ap- 
pears in  the  vulva,  suggests  to  ignorant  persons  that  the  fetus 
should  be  extracted  by  pulling  upon  the  arm.  The  result  of 


Fig.  81. — Transverse  position  of  the  fetus;  head  upon  the  left  side. 

this  is  to  wedge  the  shoulders  more  firmly  in  the  pelvic  brim. 
Fetal  death  usually  occurs  early  in  labor  through  direct  pres- 
sure, and  often  because  the  cord  prolapses  and  becomes  com- 
pressed between  the  body  of  the  child  and  the  side  of  the 
pelvis. 

Proiftiylactic  Treatment. — Such  treatment  as  is  best  to  se- 
cure proper  rotation  in  all  spontaneous  labors  is  indicated  in 
these  cases.  Where  the  abdomen  of  the  mother  is  very 


TRANSVERSE    POSITION   OF   THE    FETUS  199 

pendulous  from  relaxation  of  the  abdominal  muscles  a  broad 
well-fitting  bandage  may  be  applied  in  the  last  months  of 
pregnancy,  and  the  uterus  held  in  the  normal  axis  of  the 
birth  canal. 

Active  Treatment. — So  great  is  the  danger  of  uterine  rup- 
ture, and  so  inevitable  is  fetal  death  unless  help  be  given 
very  promptly,  that  such  cases  should  be  given  hospital 
facilities  and  delivered  by  section  as  soon  as  possible. 


Fig.  82. — Transverse  position  of  the  fetus;  back  in  front;  head  on  the 

right  side. 


right  side. 

Where  hospital  facilities  cannot  be  obtained  an  effort  may 
be  made  to  favor  spontaneous  birth  by  causing  the  woman 
to  squat  upon  the  pelvic  floor  in  such  a  posture  that  the  leg 
of  the  mother  on  the  side  toward  which  the  head  is  lying 
should  be  strongly  flexed,  rotated  slightly  inward,  and  made 
to  press  firmly  across  the  head.  The  patient  should  lean  for- 
ward, the  left  leg  being  more  strongly  flexed  and  the  patient 


200 


MANUAL    OF   OBSTETRICS 


in  the  squatting  posture.  The  result  of  this  posture  and 
pressure  has  been  in  some  cases  to  cause  the  dislodging  of  the 
head  from  its  fixed  position,  followed  by  strong  lateral  flexion 
of  the  trunk  and  the  engagement  and  descent  of  the  breech. 
While  this  is  unsuccessful  in  most  cases  it  is  by  no  means  im- 


Fig.  83. — Transverse  position  of  the  fetus;  shoulder  presentation  with 
impaction  (after  Liepmann). 

possible,  but  cannot  supersede  operative  treatment,  if  the 
latter  can  be  obtained. 

If  rupture  of  the  membranes  is  promptly  followed  by  the 
development  of  shoulder  presentation  with  prolapse  of  the 
arm,  and  possibly  of  the  umbilical  cord,  under  complete  an- 
esthesia and  with  antiseptic  precautions,  the  operator  may 
endeavor  to  replace  the  cord  arid  carry  it  above  the  pelvic 


TRANSVERSE    POSITION    OF   THE    FETUS  201 

brim.  He  may  then  terminate  labor  by  podalic  version. 
This  procedure  becomes  exceedingly  dangerous  if  the  lower 
uterine  segment  is  greatly  distended,  when  uterine  rupture 
often  follows.  Where  hospital  facilities  are  available  and  the 
child  is  living  and  in  good  condition,  delivery  by  abdominal 
section  will  give  the  best  results  for  mother  and  child. 


Fig.  84.  —  Shoulder  presentation  with  impaction,  and  prolapse  of  the 
arm  with  threatened  uterine  ruture. 


, 
arm  with  threatened  uterine  rupture 

In  neglected  cases  where  the  child  is  dead  when  the  pa- 
tient is  seen  and  where  uterine  rupture  threatens,  the  fetus 
must  be  removed  by  embryotomy  or  section.  The  fetal 
body  and  the  prolapsed  arm  and  shoulder  form  a  wedge,  the 
broad  end  of  which  is  impacted  in  the  pelvic  brim  while  the 
narrow  edge  is  presenting.  To  discompose  this  wedge  the 


202  MANUAL   OF   OBSTETRICS 

operator  must  grasp  the  arm  and  pull  it  gently  but  strongly 
downward  and  then  with  long  blunt-pointed  stout  scissors 
amputate  the  shoulder  and  remove  the  arm.  This  lessens 
the  bulk  of  the  presenting  tissues  sufficiently  to  permit  the 
safe  performance  of  podalic  version.  Others  prefer  to  per- 
form decapitation  by  the  hook  or  loop.  After  this  the  limbs 
of  the  child  are  seized,  the  body  is  extracted,  and  afterward 
forceps  applied  to  the  head,  delivery  being  effected  in  that 
manner.  In  these  cases  a  careful  examination  of  the  uterus 
should  be  made  after  delivery  to  detect  if  possible  its  rup- 
ture. 

IMPACTION  OF  TWINS 

Where  twins  are  present,  one  in  breech  presentation,  the 
other  in  head  presentation,  impaction  cannot  develop  in  the 
first  portion  of  labor;  but  if  the  child  first  born  is  dead  in 
breech  presentation,  the  aftercoming  head  may  become 
wedged  with  the  head  of  the  other  twin,  so  that  the  occiput 
of  one  is  beneath  the  chin  of  the  other.  This  will  result  in 
bringing  both  heads  at  the  brim  of  the  pelvis  in  such  position 
that  descent  and  delivery  will  be  impossible.  Fetal  death 
soon  occurs,  the  lower  uterine  segment  becomes  greatly  dis- 
tended, and  the  mother  is  exposed  to  the  dangers  of  rupture. 

Diagnosis. — When  one  twin  is  born  as  far  as  the  shoulders 
and  there  is  delay  in  expulsion  of  the  head,  a  careful  examina- 
tion should  be  made  to  ascertain  the  cause.  In  all  cases  of 
twin  delivery  care  must  be  taken  in  extracting  the  first  twin 
if  it  presents  by  the  breech  so  that  impaction  may  not  de- 
velop. 

Active  Treatment. — Embryotomy  is  the  only  form  of 
treatment  indicated,  unless  in  neglected  cases  where  the 
mother  was  infected  on  admission  to  hospital,  in  which  case 
it  might  be  safer  to  deliver  her  by  the  Porro  operation.  The 
removal  of  the  body  of  the  uterus  and  the  fixation  of  the 
stump  outside  the  peritoneal  cavity,  should  save  her  from 
septic  infection.  If  abdominal  section  be  not  performed  the 
head  of  the  twin  first  presenting  should  be  severed  by  cutting 
through  the  neck,  and  the  presenting  part  of  the  body  of  the 
first  twin  should  be  removed.  Under  complete  anesthesia 
the  uterus  should  be  relaxed  as  much  as  possible,  the  severed 


POSTERIOR   ROTATION   OF   THE   TRUNK 


203 


head  pushed  upward  into  the  uterus,  and  the  remaining  twin 
extracted  by  forceps  or  version.  The  severed  head  may  then 
be  brought  by  pressure  to  the  pelvic  brim  and  made  to  de- 
scend into  the  pelvic  cavity,  whence  it  can  be  extracted  by 
forceps. 

POSTERIOR  ROTATION  OF  THE  TRUNK 

In  breech  presentation  and  in  abnormal  rotation  in  other 
presentations  the  back  of  the  child  may  rotate  posteriorly. 


Fig.  85. — Breech  presentation,  first  position;  extraction  of  the  breech 
by  introducing  the  fingers  into  the  groins. 


If  the  breech  comes  first  this  will  bring  the  occiput  of  the 
child  behind  at  the  moment  of  birth.  Should  the  chin  then 
become  extended  and  lodge  behind  the  symphysis,  the  head 
may  become  impacted  and  the  child  be  lost  through  birth 
pressure. 


204 


MANUAL   OF   OBSTETRICS 


Fig.  86. — The  hips  passing  over  the  pelvic  floor. 


Fig.  87.— Delivering  the  limbs  in  breech  presentation  as  the  breech 

emerges. 


POSTERIOR    ROTATION    OF   THE    TRUNK  205 


Fig.  88. — Bringing  down  the  arms  by  traction  upon  the  child's  pelvis. 


Fig.  89. — Bringing  down  the  posterior  arm. 


206 


MANUAL   OF   OBSTETRICS 


Fig.  90. — Breech  presentation;  the  posterior  arm  delivered.      Bringing 
down  the  anterior  arm. 


Fig.  91. — Raising  the  child's  body  wrapped  in  a  towel,  and  pressing 
strongly  downward  and  backward  behind  the  pubes  upon  the  occiput. 


POSTERIOR   ROTATION    OF   THE   TRUNK 


207 


Prophylactic  Treatment. — Posterior  rotation  of  the  back 
should  always  be  kept  in  mind  in  delivering  breech  cases. 
So  soon  as  the  operator  can  control  the  limbs  of  the  fetus 


Fig.  92. — Breech  presentation.     Delivering  the  head  \?hen  the  occiput 
turns  posteriorly. 


the  pelvis  should  be  rotated  anteriorly  in  accordance  with 
the  original  position  of  the  back  on  the  left  or  right  side.  If 
care  be  taken  to  carry  out  this  simple  procedure  as  the  body 


208 


MANUAL    OF   OBSTETRICS 


is  extracted  the  back  can  be  turned  in  front  and  the  occiput 
brought  under  the  pelvic  arch. 

Active  Treatment. — Where,  however,  the  case  is  not  seen 
until  the  body  of  the  child  is  expelled  with  the  back  posterior, 
the  patient  must  be  placed  at  the  extreme  edge  of  the  bed  or 
table,  and  the  body  of  the  child  allowed  to  hang  downward. 


Fig.  93. — Delivery  of  the  head,  the  vertex  anterior. 


The  fingers  of  the  operator  may  then  be  placed  in  the  child's 
mouth,  the  body  and  head  rotated  in  the  oblique  diameter 
of  the  pelvis,  and  by  traction  upon  the  mouth  the  chin  dis- 
lodged and  the  face  brought  down  in  the  anterior  extremity 
of  the  oblique  diameter.  If  the  forehead  can  be  made  to 
lodge  behind  the  pubes  the  child's  body  may  then  be  strongly 


POSTERIOR    ROTATION    OF    THE    TRUNK 


209 


raised  and  the  occiput  delivered  over  the  pelvic  floor  by  strong 
flexion  of  the  head.  Should  this  procedure  fail  it  is  some- 
times necessary  to  apply  forceps  or  do  craniotomy  on  the 
after-coming  head  in  these  cases. 


Fig.    94. — The    birth    of    the    after-coming  head    aided    by   pressure 
beneath  the  pubes. 


POSTERIOR  ROTATION  OF  THE  TRUNK  IN  HEAD 
PRESENTATION 

In  head  presentation  the  shoulders  and  trunk  naturally 
follow  the  rotation  of  the  presenting  portion  of  the  head. 


210 


MANUAL   OF    OBSTETRICS 


Persistent  posterior  rotation  of  the  trunk  is  sometimes  a 
serious  complication  in  endeavoring  to  rectify  posterior  ro- 
tation of  the  head.  This  usually  occurs  where  the  amniotic 
liquid  has  completely  escaped,  and  the  body  of  the  child  is 


Fig.  95. — The  extraction  of  the  head  in  flexion. 

firmly  grasped  in  the  tetanic  contraction  of  the  uterine  mus- 
cle. If  the  uterus  be  relaxed  as  completely  as  possible  with 
chloroform  it  is  usually  possible  to  rotate  the  shoulders  and 
trunk  through  the  oblique  diameter  and  thus  to  deliver. 


UTERINE   INERTIA  211 

IMPACTION  OF  THE  SHOULDERS 

In  various  presentations  and  positions  the  shoulders  may 
become  impacted  across  the  pelvic  brim  during  labor.  This 
usually  arises  from  disproportion,  the  child  being  too  large 
for  the  mother.  In  these  cases  the  simplest  method  for  les- 
sening the  breadth  of  the  fetal  shoulders  is  to  cut  one  or  both 
clavicles — the  procedure  known  as  cleidotomy.  "  This  may 
be  done  with  strong  blunt  scissors,  the  fingers  of  one  hand 
guarding  the  mother's  tissues  while  the  other  hand  uses  the 
instrument.  Severing  the  clavicles  causes  the  shoulders  to 
collapse  and  gradually  lessens  the  bisacromial  diameter. 

Posterior  rotation  of  the  trunk  may  often  be  inferred  from 
heart  sounds.  As  the  back  recedes  the  heart  sounds  may  at 
first  becomes  less  distinct,  and  finally  are  recognized  more 
clearly  as  the  child's  chest  is  turned  toward  the  mother's 
anterior  abdominal  wall. 

PROLONGED  LABOR 

No  time  limit  can  be  placed  upon  labor.  In  patients 
who  are  not  of  a  nervous  temperament  the  first  stage  of  labor 
may  last  for  several  days,  and  still  successful  spontaneous 
birth  occur.  Labor  is  prolonged  when  its  duration  exceeds 
the  physiological  endurance  of  the  patient,  or  when  there  is 
some  condition  present  like  contracted  pelvis,  which  makes 
spontaneous  labor  impossible. 

UTERINE  INERTIA 

This  most  frequent  cause  of  prolonged  labor,  when  dis- 
proportion is  absent,  may  arise  from  several  causes.  The 
most  common  is  undue  sensitiveness  to  the  pain  caused  by 
uterine  contraction.  This  is  most  often  seen  in  badly  nour- 
ished, ill-developed,  neurotic  primipara,  or  in  multiparse  who 
have  become  so  depleted  that  uterine  neuralgia  is  present. 
Toxemia  is  a  not  infrequent  cause  of  deficient  muscular  and 
nervous  force  in  labor.  The  uterine  muscle,  like  any  other, 
may  become  exhausted  in  labor,  when  uterine  contractions 
will  cease  from  inertia.  In  some  patients  a  pathological 
condition  of  the  uterine  muscle,  as  multiple  small  fibromata, 
may  make  normal  uterine  action  impossible. 


212  MANUAL   OF   OBSTETRICS 

Rigidity  of  the  Soft  Parts. — When  the  genital  tract  is 
poorly  developed  or  the  cervix  unusually  long  and  resisting, 
or  the  patient  a  primipara  considerably  over  the  average  age 
of  childbirth,  labor  may  be  greatly  prolonged  because  a  rigid 
cervix  dilates  slowly,  and  the  rigid  perineum  and  pelvic 
floor  do  not  relax  to  permit  the  expulsion  of  the  child.  In 
some  cases  spasmodic  contraction  of  the  cervix  and  spas- 
modic rigidity  of  the  pelvic  floor  delay  labor  through  in- 
creased nervous  irritation.  In  multipart  where  the  cervix 
has  been  repeatedly  torn,  and  infection  may  have  resulted, 
the  cervix  may  be  so  filled  with  scar  tissue  that  it  dilates  very 
slowly  and  imperfectly,  and  thus  delays  labor.  In  patients 
where  the  normal  secretion  of  the  cervix  and  vagina  is  ab- 
sent muscular  rigidity  results  with  delay. 

Nervom  Exhaustion. — This  very  important  factor  in  pro- 
longed labor  cannot  be  accurately  assigned  to  any  distinct 
anatomical  cause.  It  is  seen  in  patients  ill-nourished  and 
in  whom  the  nervous  system  is  badly  developed,  highly 
sensitive  and  excitable.  Such  patients  commonly  demand 
anesthetics  or  anodines,  the  uterine  muscle  becomes  easily 
fatigued,  and  after  delivery  they  are  liable  to  severe  nervous 
collapse  or  shock. 

Diagnosis. — The  diagnosis  of  uterine  inertia,  rigidity  of 
the  soft  parts,  and  nervous  exhaustion  complicating  labor,  is 
most  important.  The  obstetrician  must  first  satisfy  him- 
self that  the  pelvis  and  the  child  are  proportionate  in  size, 
and  that  he  is  not  dealing  with  contracted  pelvis  or  an  ex- 
cessively large  child,  or  hydrocephalus,  or  monstrosity.  He 
must  next  determine  accurately  that  the  presentation  and 
position  are  favorable  for  spontaneous  birth.  It  is  obvious 
that  a  patient  must  become  nervously  exhausted  in  labor 
and  suffer  uterine  inertia  if  the  fetus  be  in  transverse  posi- 
tion shoulder  presentation,  and  spontaneous  birth  be  im- 
possible. 

Face  presentation,  brow  presentation,  parietal  bone  pres- 
entation, and  abnormal  rotation  of  the  presenting  part  com- 
plicating labor,  are  frequent  causes  for  uterine  inertia  and 
nervous  exhaustion.  One  of  these  may  be  suspected  when  a 
patient  with  normal  pelvis  and  fetus  enters  labor  and  does  not 
go  on  naturally.  Premature  rupture  of  the  membranes  and 


UTERINE   INERTIA  213 

the  escape  of  the  amniotic  liquid  before  dilatation  is  at  least 
half  completed  is  a  frequent  cause  of  nervous  exhaustion. 

To  make  an  accurate  diagnosis  a  thorough  anatomical 
examination  must  first  be  made.  The  condition  of  the  blad- 
der and  the  rectum  must  also  be  ascertained,  for  a  full  bladder 
may  occasion  such  distress  as  to  interfere  with  labor,  and  if 
the  rectum  be  full  of  hardened  feces  the  descent  of  the  child 
may  be  delayed.  If  no  anatomical  cause  can  be  found  for 
delay  the  vital  condition  of  the  patient  must  next  be  ascer- 
tained. If  her  pulse  be  good,  her  temperature  normal,  the 
surface  of  the  body  normal,  the  membranes  unruptured,  the 
fetus  in  normal  position  and  presentation,  and  the  bladder 
and  rectum  of  the  patient  emptied,  the  cessation  of  labor 
pains  for  a  short  time  should  give  no  anxiety.  So  far  as 
uterine  inertia  and  nervous  exhaustion  are  concerned,  the 
important  clinical  fact  must  be  borne  in  mind  that  except  in 
the  case  of  Cesarean  section  it  is  unwise  to  empty  the  uterus 
by  vaginal  delivery  unless  the  uterus  is  contracting.  Serious 
relaxation  and  post-partum  hemorrhage  with  shock,  may  fol- 
low unless  this  precaution  is  observed. 

Treatment. — Where  uterine  inertia  only  is  present  the 
bladder  of  the  patient  should  be  emptied  thoroughly  by 
catheter  and  the  lower  bowel  by  a  copious  warm  injection. 
The  temperature  of  the  patient's  room  should  be  made  as 
comfortable  as  possible  and  she  should  be  put  at  absolute 
rest,  with  the  hope  that  natural  sleep  may  result.  If  her 
pains  are  nagging  and  irritating  and  exhausting,  morphia 
with  atropin  should  be  given  hypodermatically.  If  the 
patient  shows  signs  of  exhaustion  a  moderate  quantity  of 
alcoholic  stimulant  with  the  morphin  and  atropin  will  be  of 
value.  Rest  and  sleep  usually  follow,  and  labor  will  begin 
with  renewed  activity  when  the  patient  has  rested. 

Where  the  uterus  is  evidently  exhausted  and  the  patient 
threatened  with  nervous  exhaustion,  the  treatment  by  mor- 
phia, atropin  and  alcohol,  is  useful  until  rest  has  been  pro- 
cured. When  the  patient  again  becomes  wakeful  she  will  re- 
quire a  stimulant  to  uterine  contractions.  For  this  purpose 
at  present  we  have  two  valuable  remedies  which  should  be 
given  hypodermatically;  one  is  strychnia,  the  sulphate 
or  phosphate,  the  dose  being  from  -^  to  -^V  The  effect  of 


214  MANUAL   OF   OBSTETRICS 

strychnia  is  often  increased  if  the  patient  takes  by  mouth  30 
drops  of  brandy  and  30  drops  of  aromatic  spirits  of  am- 
monia. Pituitrin  is  also  of  value  for  uterine  inertia  and 
should  be  given  hypodermatically  deeply  into  the  muscles, 
in  doses  of  from  1  to  1.5  c.c.  It  should,  however,  be  especially 
borne  in  mind  that  pituitrin  must  not  be  given  until  the  cer- 
vix is  two-thirds  dilated  and  the  conditions  favorable  for 
vigorous  uterine  action  and  prompt  expulsion  of  the  child. 
Pituitrin  causes  rapid  and  vigorous  uterine  contractions,  and 
where  it  has  been  given  before  dilatation  was  sufficiently  ad- 
vanced dangerous  tears  of  the  cervix,  and  in  some  cases  rup- 
ture of  the  uterus,  have  resulted.  In  multiparous  patients 
with  two-thirds  dilatation  of  the  cervix,  and  the  membranes 
present,  if  the  conditions  are  favorable  for  labor,  rupture  of 
the  membranes  will  usually  be  followed  by  increased  uterine 
action.  When  patients  are  threatened  with  nervous  ex- 
haustion digitalin  may  be  given  with  strychnia  hypoder- 
matically with  advantage. 

For  uterine  inertia  and  nervous  exhaustion  in  labor,  quinin, 
alcohol  in  large  doses,  and  ergot,  have  all  been  used.  Quinin 
is  unreliable,  ergot  produces  tetanic  action  of  the  uterus  and 
frequently  destroys  the  fetus,  and  large  doses  of  alcohol  are 
sedative  and  not  stimulating.  None  of  these  drugs  can  be 
recommended.  Where  it  has  been  necessary  to  stimulate 
the  patient  for  uterine  inertia  or  nervous  exhaustion  during 
labor,  especial  care  must  be  taken  to  guard  against  shock 
after  delivery.  Strychnia  hypodermatically  should  be  re- 
peated so  soon  as  the  uterus  is  empty,  and  ergot  may  then  be 
given  hypodermatically  freely,  and  with  good  results. 

Rigidity  of  the  soft  parts  delaying  labor  may  be  treated  by 
artificial  dilatation  with  silk  or  rubber  dilating  bags.  Among 
these  the  French  bag  of  Champetier  de  Ribes,  and  those  de- 
vised by  Voorhees  and  Pomeroy,  are  especially  useful.  The 
de  Ribes  bag  is  inelastic,  made  of  silk,  and  covered  with  im- 
pervious material.  The  Voorhees  bag  is  of  rubber:  the 
Pomeroy  bag  is  double,  containing  a  portion  which  goes  within 
the  cervix  and  another  portion  which  dilates  the  vagina. 
To  introduce  this,  if  the  patient  be  sensitive,  partial  anes- 
thesia may  be  necessary.  The  bladder  and  rectum  having 
been  emptied  under  anesthesia,  the  patient  is  placed  across 


UTERINE    INERTIA  215 

the  bed  or  upon  a  table,  a  gentle  irrigation  of  1  per  cent, 
lysol  is  given,  and  the  gloved  fingers  of  the  left  hand  intro- 
duced beneath  the  cervix.  The  bag  folded  in  forceps  is  in- 
troduced under  the  guidance  of  the  fingers  and  passed  within 
the  internal  os.  An  assistant  then  fills  the  bag  with  normal 
salt  solution  or  1  per  cent,  lysol,  with  a  piston  syringe,  until 
the  pressure  of  the  fluid  in  the  bag  forces  the  piston  of  the 
syringe  outward.  A  clamp  is  then  placed  upon  the  tube  of 
the  bag.  The  vagina  should  be  moderately  tamponed  with 
10  per  cent,  iodoform  or  sterile  gauze.  The  tube  of  the  bag 
is  carried  upward  above  the  pubes  and  maintained  in  place 
by  a  binder  or  bandage. 

Before  inserting  the  bags  they  should  be  thoroughly  tested 
to  see  that  they  do  not  leak  and  that  they  are  sound.  Some 
prefer  to  attach  a  weight  to  the  tube  of  the  bag  and  thus 
to  make  constant  traction  until  the  patient  expels  the  bag 
spontaneously.  As  the  parts  dilate  more  fluid  may  be 
forced  into  the  bag  until  its  capacity  has  been  reached. 

The  disadvantages  in  the  use  of  bags  are  the  pain  which 
they  cause,  which  is  often  severe  and  sometimes  intolerable. 
Bags  have  displaced  a  low  attached  placenta  and  given  rise 
to  hemorrhage.  The  bursting  of  a  bag  has  caused  fluid  or 
air  to  enter  the  uterine  sinuses.  Dilating  bags  sometimes 
displace  the  presenting  part,  and  change  a  favorable  into  an 
unfavorable  mechanism.  In  cases  where  the  cervix  is  filled 
with  scar  tissue  bags  are  not  strong  enough  to  dilate  the  parts 
adequately. 

The  advantages  of  bags  are  the  fact  that  they  can  readily 
be  used  in  private  houses,  that  they  do  not  require  incision 
for  their  introduction,  and  that  in  some  degree  they  imitate 
the  pressure  of  a  firm  and  full  bag  of  waters. 

If  bags  be  employed  successfully  the  presence  of  the  bag 
will  not  only  dilate  the  soft  parts  but  stimulate  uterine  con- 
tractions. When  dilatation  is  complete  the  bags  may  be 
removed  and  the  patient  allowed  to  deliver  herself,  or  if 
necessary  some  vaginal  operation  may  be  done.  In  using 
bags,  if  the  membranes  are  unruptured,  care  should  be  taken 
not  to  rupture  them,  and  if  the  membranes  have  been  rup- 
tured when  the  bag  was  introduced,  when  it  is  removed  an 
examination  should  be  made  to  see  that  a  loop  of  cord  has  not 


216  MANUAL   OF   OBSTETRICS 

prolapsed.     This  sometimes  follows  the  removal  of  a  dilating 


Where  haste  is  necessary  because  the  patient  is  in  a  critical 
condition,  and  the  soft  parts  are  rigid  and  undilatable,  the 
birth  canal  must  be  opened  by  incision.  If  the  cervix  only 
seems  to  be  resisting  it  may  be  incised  by  four  cuts  extending 
obliquely  above  and  below.  To  avoid  the  uterine  arteries  the 
lateral  surfaces  of  the  cervix  should  not  be  incised.  Incision 
of  the  cervix  has  given  place  among  modern  operators  to  vag- 
inal Cesarean  section,  which  will  be  described  under  obstetric 
operations. 

Some  operators  prefer  to  dilate  a  rigid  cervix  or  pelvic 
floor  by  the  gloved  hand.  This  is  only  possible  when  the 
cervix  has  practically  become  obliterated  in  primiparse,  or 
when  it  is  not  unduly  hard  and  resisting  in  multiparse.  In 
doing  this  the  writer  prefers  to  introduce  the  longest  finger  of 
each  hand  and  to  move  the  hands  through  each  half  of  the 
circle,  adding  other  fingers  as  the  cervix  dilates,  until  four 
fingers  of  each  hand  can  be  introduced  at  full  dilatation.  No 
effort  should  be  made  to  force  the  fist  through  the  cervix 
until  it  is  completely  dilated,  for  such  an  effort  might  cause 
rupture  of  the  uterus.  Others  prefer  to  introduce  one  finger, 
sweeping  it  about  the  cervix,  then  other  fingers,  until  four  are 
used  for  dilatation.  This  maneuver  requires  experience,  dex- 
terity and  strength,  and  is,  unfortunately,  inefficient  in  those 
cases  which  are  most  serious  and  where  the  cervix  must  be 
opened  most  efficiently  and  promptly. 

To  dilate  the  vagina  and  pelvic  floor  the  gloved  hand  is 
especially  valuable.  Here  the  hand  introduced  may  be 
gradually  closed  into  the  fist,  and  rotated  gently,  until  the 
vagina  and  pelvic  floor  have  been  thoroughly  dilated. 

In  cases  where  dilatation  is  almost  complete  and  it  is 
necessary  to  apply  forceps,  the  fingers  should  be  used  to  se- 
cure as  complete  dilatation  as  possible  before  the  instrument 
is  applied.  Under  ether  this  should  be  an  invariable  pro- 
cedure. 

Rigidity  of  the  soft  parts  can  to  some  extent  be  influenced 
by  repeated  hot  irrigations  with  antiseptic  fluid,  of  which 
lysol  1  per  cent,  is  best.  This  has  the  disadvantage  that 
it  is  uncertain  and  tedious,  that  it  washes  away  the  natural 


DISPROPORTION   CAUSING    PROLONGED    LABOR  217 

secretion  which  lubricates  the  birth  canal,  and  exposes  the 
patient  to  additional  risk  of  infection. 

DISPROPORTION  CAUSING  PROLONGED  LABOR 

When  pelvis  and  child  are  disproportionate,  but  the  differ- 
ence in  size  is  not  so  great  as  to  make  spontaneous  labor  im- 
possible, birth  may  be  greatly  prolonged.  To  secure  delivery 


Fig.  96. — Disproportion  between  mother  and  child;    the   mother  with 
rhachitic  pelvis  (after  Liepmann). 

in  these  cases  the  fetal  skull  must  be  compressed  to  the  ut- 
most and  the  head  excessively  molded  and  elongated.  Such 
a  head  is  often  called  "wire-drawn. "  This  process  consumes 
considerable  time  and  increases  very  much  the  difficulty  of 
labor.  Abnormalities  in  the  shape  of  the  fetal  cranium  may 
also  prolong  labor  and  delay  rotation  of  the  presenting  part. 
An  excessively  hard  fetal  head  may  mould  with  great  diffi- 
culty and  greatly  prolong  gestation. 


218  MANUAL    OF    OBSTETRICS 

Diagnosis. — The  diagnosis  of  disproportion  between 
mother  and  child  should  be  begun  with  the  measurement  of 
the  mother's  pelvis.  When  this  is  decisive,  it  will  give  the 
obstetrician  valuable  information.  The  positive  diagnosis 
of  disproportion  is  made  by  accurate  vaginal  examination 
and  by  accurate  and  painstaking  observation  of  the  progress 
of  labor.  When  the  head  enters  the  pelvic  brim  only,  and 
after  ample  time  does  not  mould  properly  and  descend,  the 
position  of  the  fetus  being  normal  and  good  uterine  contrac- 
tions being  present,  disproportion  may  be  recognized.  When 
in  spite  of  favorable  conditions  the  head  remains  movable 
above  the  pelvic  brim,  and  by  combined  examination  is  evi- 
dently large,  disproportion  is  present. 

The  diagnosis  of  this  condition  is  one  of  the  most  important 
with  which  the  obstetrician  has  to  do.  A  mistake  in  this 
diagnosis  would  lead  to  a  mistake  in  treatment  which  may 
cause  the  life  of  the  child,  or  both  mother  and  child. 

The  diagnosis  must  be  made  by  palpation,  auscultation, 
pelvimetry,  and  palpation  of  the  head  and  pelvis.  The  uri- 
nary bladder  of  the  patient  must  first  be  completely  emptied, 
and  if  there  be  any  doubt  of  this  the  catheter  should  be  em- 
ployed. If  the  patient  is  sensitive  and  threatened  with  ex- 
haustion, partial  anesthesia  may  be  of  great  value.  By  pal- 
pation the  obstetrician  will  find  that  the  head  is  in  the  pelvic 
brim,  but  not  descended  and  engaged.  This  is  often  a  diffi- 
cult point  to  recognize  by  palpation,  but  it  must  be  remem- 
bered that  the  head  is  still  in  the  pelvic  brim  until  it  is  virtu- 
ally within  the  pelvic  cavity  and  below  the  promontory  of  the 
sacrum.  In  extreme  disproportion  the  diagnosis  is  compara- 
tively easy  because  the  head  in  these  cases  does  not  even 
enter  the  pelvic  brim. 

By  vaginal  palpation  the  obstetrician  must  first  rule  out 
presentation  of  the  parietal  bone  or  brow  presentation.  He 
must  then  locate  the  spines  of  the  ischia  and  determine  the 
position  of  the  head  with  relation  to  these  landmarks.  By 
gentle  pressure  he  can  ascertain  whether  the  head  is  movable 
or  whether  it  is  firmly  fixed  in  the  pelvis.  The  position  and 
presentation  should  be  accurately  made  out,  and  the  situa- 
tion of  the  head  with  relation  to  the  pelvis.  While  it  is  easy 
to  palpate  the  head  if  the  membranes  are  ruptured,  it  is  not 


DISPROPORTION    CAUSING   PROLONGED   LABOR  219 

impossible  before  the  amniotic  liquid  escapes,  and  the  pres- 
ence of  the  membranes  should  not  prevent  the  natural  en- 
gagement and  descent  of  the  presenting  part. 

In  multiparous  patients  in  whom  engagement  and  descent 
do  not  develop  at  the  beginning  of  labor,  it  may  be  difficult 
to  accurately  ascertain  the  comparative  size  of  the  mother 
and  child.  Here  combined  examination  is  valuable,  and  pel- 
vimetry  and  the  history  of  previous  labors  must  not  be 
neglected. 

Treatment. — Many  obstetric  disasters  arise  in  cases  of 
disproportion,  and  in  no  condition  is  it  more  important  to 
make  a  correct  choice  of  the  method  of  treatment. 

It  is  absolutely  necessary  for  the  successful  management' 
of  such  a  case  that  the  obstetrician  ascertains  clearly  whether 
engagement  is  or  is  not  present.  Having  learned  that  the 
size  of  the  mother's  pelvis  is  such  that  spontaneous  birth  is 
possible,  and  sufficient  time  for  uterine  action  having  elapsed 
to  secure  engagement,  if  this  be  not  present  it  is  a  strong  in- 
dication that  disproportion  is  present.  So  important  is  this 
decision  that  partial  anesthesia  should  be  used,  if  it  cannot  be 
made  without  it.  If  the  head  be  well  engaged,  with  at  least 
three-fourths  its  bulk  in  the  pelvic  cavity,  the  obstetrician 
must  next  determine  if  possible  whether  the  head  is  unusually 
ossified.  This  may  be  inferred  by  examining  the  sutures  and 
fontanelles,  when,  if  ossification  is  unusually  advanced,  the 
fontanelle  will  be  smaller  than  normal  and  the  sutures  com- 
pletely or  partially  closed.  Palpation  should  also  determine 
the  presence  or  absence  of  moulding  of  the  head.  If  engage- 
ment is  well  advanced  and  moulding  is  present,  and  the  pa- 
tient's general  condition  indicates  that  delivery  is  necessary, 
the  obstetrician  must  ascertain  the  vital  condition  of  the 
child.  This  may  be  inferred  from  the  frequency  and  char- 
acter of  the  heart  sounds.  Rapid  feeble  heart  sounds,  or 
slow  and  feeble  heart  sounds,  are  alike  unfavorable.  The 
entire  absence  of  heart  sounds  indicates  fetal  death. 

Should  the  fetus  be  dead  and  disproportion  present,  de- 
livery should  be  effected  by  craniotomy,  in  the  interests  of 
the  mother.  If,  however,  the  fetus  be  living  and  in  fair  con- 
dition, with  favorable  position  and  presentation,  engage- 
ment and  at  least  partial  descent,  and  delivery  required 


220  MANUAL   OF   OBSTETRICS 

in  the  interests  of  mother  and  child,  the  forceps  should  be 
chosen. 

With  the  child  living  and  in  good  condition,  and  moderate 
disproportion  present,  it  may  be  possible  to  enlarge  the  moth- 
er's pelvis  and  thus  permit  vaginal  delivery.  This  may  be 
done  by  pubiotomy  or  symphysiotomy. 

Where  mother  and  child  are  disproportionate,  if  vaginal 
delivery  be  possible,  the  fetus  may  undergo  severe  birth- 
pressure  and  may  be  born  partially  asphyxiated.  Addi- 
tional care  will  be  necessary  for  the  child  for  some  time  after 
its  birth. 

Where  disproportion  is  present  and  engagement  and  de- 
scent do  not  develop  after  the  mother's  general  condition  has 
received  attention,  and  reasonable  time  has  elapsed,  delivery 
must  be  effected  by  a  major  operation — abdominal  Cesa- 
rean  section,  pubiotomy  or  symphysiotomy. 

IMPACTION  OF  THE  FETUS 

When  position  and  presentation  are  such  that  normal 
mechanism  becomes  impossible,  strong  uterine  and  abdom- 
inal contractions  may  force  the  fetus  into  the  pelvic  brim, 
causing  impaction.  Where  the  presenting  part  rotates  ab- 
normally a  similar  condition  may  develop;  thus  posterior 
rotation  of  the  chin,  shoulder  presentation  transverse  posi- 
tion, with  prolapse  of  the  arm,  result  in  impaction  unless  arti- 
ficial aid  be  given.  The  results  of  impaction  are  the  death  of 
the  child  and  the  death  of  the  mother  from  infection,  rup- 
ture of  the  uterus,  or  exhaustion. 

Diagnosis. — In  shoulder  presentation  transverse  position, 
the  diagnosis  of  impaction  is  made  by  recognizing  the  pro- 
truding arm,  by  palpating  the  abdomen  with  the  urinary 
bladder  of  the  patient  empty,  and  by  vaginal  examination. 
Where  impaction  develops  when  the  head  presents,  abdominal 
palpation  gives  less  information,  and  a  positive  diagnosis  must 
be  made  by  careful  vaginal  palpation.  If  the  patient  has 
been  long  in  labor  and  the  vagina,  pelvic  floor  and  perineum 
are  swollen,  an  exact  diagnosis  of  the  position  of  the  impacted 
head  may  be  impossible.  But  the  clinical  history,  the 
physical  state  of  the  mother,  the  cessation  of  the  natural 


RUPTURE  OF  THE  UTERUS  221 

phenomena  of  labor,  with  the  vaginal  examination,  should 
make  diagnosis  possible. 

Treatment. — In  most  of  these  cases  the  life  of  the  child  is 
lost  or  must  inevitably  be  sacrificed.  The  obstetrician  need 
pay  but  little  heed  to  the  fetus.  In  attempting  to  relieve 
the  mother  he  must  first  ascertain  accurately  the  condition 
of  the  uterine  muscle.  If  it  be  in  tetanic  contraction,  if  the 
contraction  ring  be  present  and  the  lower  segment  be  greatly 
distended,  uterine  rupture  is  threatened.  His  efforts  to  re- 
move the  impacted  fetus  may  precipitate  this  accident.  In 
such  a  case  the  bulk  of  the  fetus  must  be  lessened  before  an 
attempt  is  made  to  deliver  it  through  the  vagina.  If  the 
head  presents  craniotomy  should  be  done;  if  the  shoulder 
presents  the  wedge  must  be  decomposed  by  amputating  the 
arm  at  the  shoulder,  or  by  decapitation.  If  the  patient  be 
long  in  labor  with  shoulder  presentation,  and  be  infected, 
abdominal  section  with  the  removal  of  the  greater  part  of 
the  uterus,  is  indicated. 

Where  impaction  is  present  it  may  be  necessary  to  use  an- 
esthesia to  make  a  complete  diagnosis  and  to  carry  out  any 
manipulation  which  is  supposed  to  improve  the  condition  of 
mother  or  child. 

RUPTURE  OF  THE  UTERUS 

This  most  dangerous  accident  is  followed  by  the  complete 
cessation  of  labor,  and  if  the  mother  receives  no  aid  she  will 
die  of  peritonitis  or  exhaustion. 

Etiology. — Rupture  of  the  uterus  usually  occurs  from  ab- 
normal mechanism  in  labor  or  disproportion  which  results  in 
impaction.  The  lower  uterine  segment  becomes  over-dis- 
tended and  greatly  thinned  by  the  presenting  part,  the  upper 
portion  of  the  uterus  is  in  tetanic  contraction,  and  the  lower 
border  of  the  expulsive  segment  can  be  plainly  made  out  as  a 
ridge  extending  transversely  across  the  uterus  above  the 
pubes.  Rupture  usually  occurs  transversely  upon  the  an- 
terior surface  at  the  junction  of  the  lower  and  upper  uterine 
.segments;  less  often  the  posterior  portion  is  torn;  very  rarely 
both  anterior  and  posterior  surfaces  are  ruptured.  The  early 
escape  of  the  amniotic  liquid  predisposes  to  rupture.  In  ill- 
developed  primiparffi  where  the  uterus  is  anatomically  defi- 


222  MANUAL    OF   OBSTETRICS 

cient,  rupture  may  occur;  while  multiparse  who  have  borne 
children  rapidly,  and  under  bad  conditions,  may  develop 
changes  in  the  uterine  muscle  which  readily  permit  rupture. 
So  rupture  of  the  uterus  has  occurred  in  spontaneous  labor 


Fig.  97. — The  most   usual  rupture  of  the  uterus,  transversely  across 
the  anterior  wall.     The  contraction  ring  markedly  developed. 


when  apparently  normal  progress  was  going  on.  It  has 
occurred  without  excessive  uterine  contractions  and  for  no 
apparent  cause.  In  these  cases,  however,  when  the  uterine 
muscle  was  subjected  to  microscopic  examination  its  fibres 


RUPTURE  OF  THE  UTERUS  223 

were  found  degenerated  and  many  of  them  replaced  by  con- 
nective tissue. 

Signs  and  Symptoms. — The  signs  and  symptoms  of  uterine 
rupture  are  sudden  and  often  excruciating  pain  in  the  ab- 
domen, and  the  immediate  and  complete  cessation  of  uterine 
contractions.  Fetal  movements  cease  and  the  fetal  heart 
sounds  very  soon  disappear.  There  may  be  some  escape  of 
blood  from  the  vagina,  but  in  many  cases  this  is  absent.  The 
patient  complains  of  great  pain,  there  is  shock  with  rapid 
feeble  pulse  and  subnormal  temperature,  followed  by  gradual 
development  of  septic  infection,  fever,  peritonitis,  and  death. 

Rupture  of  the  uterus  is  rarely  confused  with  other  serious 
conditions.  In  the  early  months  of  pregnancy  rupture  of  an 
ectopic  gestation  may  be  present. 

Diagnosis. — The  diagnosis  of  rupture  of  the  uterus  is  made 
by  the  signs  and  symptoms,  by  the  immediate  cessation  of 
progress  in  labor,  the  fetus  often  receding  into  the  pelvic  or 
abdominal  cavity  so  that  it  cannot  be  felt  on  vaginal  exami- 
nation. 

The  signs  of  fetal  death  are  a  valuable  indication.  Tender- 
ness in  the  abdomen  which  rapidly  increases,  evidences  of 
shock  and  infection,  and  in  some  cases  the  palpation  of  the 
fetus  in  the  abdomen  instead  of  in  the  uterus,  complete  the 
diagnosis.  On  vaginal  examination  the  fingers  may  often 
be  passed  through  the  rent  in  the  uterine  muscle.  Some- 
times a  loop  of  intestine  prolapses  through  this  aperture. 

Treatment. — -This  condition  is  so  uniformly  fatal  that  no 
delay  should  be  permitted  in  instituting  prompt  treatment. 

If  possible,  the  patient  should  be  immediately  transported 
to  hospital.  If  shock  be  severe,  morphin  and  atropin  with 
digitalin  should  be  given  hypodermatically.  If  there  be 
much  hemorrhage,  compression  of  the  aorta  by  a  pad  and 
bandage,  or  by  what  is  termed  Momburg's  bandage,  may  be 
employed  until  the  patient  can  be  brought  into  hospital. 

So  soon  as  possible  under  antiseptic  precautions  a  thor- 
ough examination  should  be  made.  If  the  head  is  on  the 
pelvic  floor  or  in  the  pelvic  cavity  the  patient  should  be  as 
thoroughly  anesthetized  as  her  condition  permits  and  the 
fetus  extracted  in  the  gentlest  manner  possible.  So  soon  as 
this  is  done  the  gloved  hand  should  follow  the  umbilical  cord 


224  MANUAL   OF   OBSTETRICS 

into  the  uterus  and  ascertain  the  position  and  size  of  the  rent. 
The  placenta  should  be  removed  with  the  membranes  and 
blood  clot,  but  no  irrigation  should  be  practised.  If  the  rent 
be  of  moderate  size  only  and  if  there  be  not  much  hemorrhage, 
and  the  patient  cannot  be  taken  to  hospital,  an  effort  may  be 
made  to  save  the  uterus  and  the  patient's  life  as  well.  To  ac- 
complish this,  under  antiseptic  precautions  as  thoroughly  as 
possible,  a  broad  strip  of  10  per  cent,  iodoform  gauze  should 
be  carried  into  the  uterus  wfth  the  fingers  of  the  gloved  hand 
and  passed  through  the  rent  in  the  uterus  to  serve  as  a  drain. 
Sufficient  gauze  should  be  used  to  pass  well  beyond  the  uterus 
and  to  distend  the  uterine  body  with  moderate  firmness. 
This  gauze  should  be  brought  out  at  the  cervix  and  the  vag- 
ina tamponed  with  bichloride  gauze.  Strychnia  should  be 
given  hypodermatically,  care  should  be  taken  to  have  the 
patient  catheterized  at  frequent  intervals,  dry  ice  bags  and 
turpentine  stupes  should  be  placed  over  the  abdomen,  and 
the  patient  given  morphin  and  atropin,  and  strychnia  and 
digitalin  hypodermatically.  If  such  a  case  be  promptly 
treated  under  antiseptic  precautions  a  considerable  propor- 
tion are  saved.  The  child  is  almost  universally  lost. 

While  the  procedure  just  described  is  permissible  when 
hospital  facilities  cannot  be  obtained,  in  hospital  all  cases  of 
uterine  rupture  demand  immediate  abdominal  section.  In 
severe  cases  the  fetus  is  found  in  the  abdominal  cavity  and 
sometimes  the  placenta  as  well.  A  varying  quantity  of 
blood  is  also  present. 

The  operator  must  first  remove  the  child  and  its  ap- 
pendages and  then  carefully  examine  the  uterus.  An  oper- 
ator of  experience  may  try  to  save  the  uterus  if  the  rent  be 
not  very  large  and  does  not  extend  into  the  broad  ligament. 
To  do  this  the  uterus  should  be  tamponed  with  iodoform 
gauze  and  the  gauze  brought  through  the  cervix  into  the 
vagina.  If  the  uterine  wound  is  ragged  it  should  be  trimmed 
by  scissors  and  the  wound  closed  with  buried  stitches  of 
silk,  extending  through  the  muscle  only.  The  peritoneal 
covering  should  be  brought  together  by  continuous  catgut 
stitches.  The  uterus  should  be  placed  in  normal  position 
and  a  gauze  drain  passed  to  the  bottom  of  the  pelvis  behind 
the  uterus  through  the  lower  end  of  the  abdominal  incision. 


RUPTURE  OK  THE  UTERUS  225 

During  operation  the  patient  should  receive  intravenous  saline 
transfusion,  and  the  stomach  should  be  thoroughly  irrigated 
with  hot  salt  solution  before  the  patient  leaves  the  table. 
\Yhore  the  patient  is  robust  and  is  brought  promptly  to  hos- 
pital, and  has  not  had  great  hemorrhage,  and  where  the  rent  is 
favorably  situated  for  union,  this  procedure  may  be  successful. 

In  the  majority  of  cases  the  uterus  is  torn  so  extensively 
through  its  lower  segment  and  into  the  broad  ligament  that 
suture  is  unsafe.  Hysterectomy  must  be  performed,  leaving 
one  or  both  ovaries  and  removing  the  Fallopian  tubes. 
Many  obstetricians  prefer  to  extirpate  the  uterus  rather  than 
to  leave  the  cervix,  through  fear  of  infection.  Whether  the 
uterus  be  extirpated  or  hysterectomy  done,  the  pelvis  should 
be  drained  by  gauze  either  through  the  vagina  or  through  the 
lower  end  of  the  abdominal  incision.  If  the  patient's  con- 
dition permits,  the  edges  of  the  broad  ligament  should  be 
brought  together  by  continuous  catgut  and  the  pelvic  fascia 
as  well.  The  patient  will  require  free  stimulation,  as  there 
is  usually  pronounced  shock  where  rupture  is  extensive. 

Mortality. — It  cannot  be  too  strongly  urged  that  the 
patient's  best  chance  for  recovery  in  this  otherwise  fatal 
accident  lies  in  immediate  operation.  Under  favorable  cir- 
cumstances the  mortality  may  be  reduced  to  10  to  20  per 
cent.  Under  ordinary  circumstances  a  mortality  of  from 
60  to  90  per  cent,  is  not  unusual.  The  recovery  of  the  child 
after  rupture  of  the  uterus  is  a  very  rare  occurrence. 

The  Prevention  of  this  Accident. — As  many  cases  of  uter- 
ine rupture  occur  in  the  practice  of  incompetent  persons, 
and  are  clearly  preventable,  this  serious  condition  should  be 
prevented  by  restricting  the  care  of  obstetric  cases  to  com- 
petent persons,  ruling  out  ignorant  midwives  and  practi- 
tioners, and  by  educating  the  profession  and  the  laity  to 
recognize  the  necessity  for  prompt  hospital  care.  To  pre- 
vent this  accident  students  must  be  thoroughly  instructed  in 
recognizing  the  absence  of  engagement  and  descent,  the 
presence  of  impaction  of  the  fetus,  and  the  presence  of  the 
contraction  ring  and  distended  lower  segment.  The  student 
and  general  practitioner  must  realize  under  these  conditions 
that  the  patient  must  be  brought  to  hospital  as  quickly  as 
possible,  and  without  interference. 
15 


226 


MANUAL   OF   OBSTETRICS 


PROLAPSE  OF  THE  CORD  OR  FETAL  PARTS 

Prolapse  of  the  umbilical  cord  may  result  where  the  child 
is  considerably  smaller  than  the  mother's  birth  canal,  where 
the  membranes  rupture  followed  by  a  sudden  discharge  of 
a  large  quantity  of  fluid,  or  where  the  fetus  becomes  impacted 


Fig.  98. — Prolapse  of  the  cord  and  hand  (after  Liepmann). 

in  shoulder  presentation  transverse  position.  An  unusually 
long  cord  which  is  not  coiled  about  the  child  favors  prolapse. 
Diagnosis. — Prolapse  rarely  happens  before  rupture  of  the 
membranes.  Occasionally  a  loop  of  cord  descends  into  the 
membranes  if  the  head  be  much  smaller  than  the  pelvis. 
The  cord  is  usually  recognized  without  difficulty  and  it 


PROLAPSE  OF  THE  CORD  OR  FETAL  PARTS 


227 


should  at  once  be  ascertained  whether  it  still  pulsates  or 
whether  pulsation  is  diminished  or  has  ceased. 

This  accident  results  in  danger  to  the  fetus  through  com- 
pression of  the  cord  between  the  child  and  the  pelvis,  leading 
to  gradual  asphyxia.  Where  this  occurs  the  child's  move- 
ments become  at  first  more  rapid  and  violent  than  normal, 
and  finally  subside.  The  danger  to  the  mother  is  secondary 
because  of  the  abnormal  conditions  which  make  interference 
necessary. 

Treatment. — The  obstetrician  must  keep  in  mind  the 
possibility  of  prolapse  of  the  cord  in  transverse  positions 


Fig.   99. — Prolapse  of  the  cord    partly  replaced    by  the    knee-chest 
position  (after  Liepmann). 

before  the  membranes  rupture,  and  in  cases  where  it  is  neces- 
sary to  use  dilating  bags,  and  where  the  removal  of  the  bag 
is  sometimes  followed  by  prolapse  of  the  cord. 

When  this  occurs  a  choice  must  be  made  between  two 
methods  of  treatment. 

Where  the  presenting  part,  is  not  in  the  pelvic  cavity  and 
the  genital  tract  of  the  mother  is  dilated  and  dilatable,  the 
patient  should  be  anesthetized,  and  under  antiseptic  pre- 
cautions the  obstetrician  should  take  the  prolapsed  cord 
gently  in  his  thumb  and  fingers,  and  introducing  the  hand 


228  MANUAL   OF    OBSTETRICS 

carry  the  cord  above  the  pelvic  brim.  Anesthesia  should 
then  be  stopped  and  the  uterus  allowed  to  contract,  when  the 
fetus  may  descend  and  prevent  the  return  of  the  cord.  If 
when  the  hand  is  introduced  with  the  cord  the  uterus  is  not 
found  in  tetanic  contraction  and  the  fetus  freely  movable, 
some  operators  prefer  to  perform  internal  podalic  version, 
which  prevents  the  further  prolapse  of  the  cord.  "  Some  prefer 
the  use  of  a  repositor  in  place  of  the  hand,  but  these  instru- 
ments are  not  as  reliable  as  the  hand  and  do  not  give  the 
operator  the  same  information.  Cord  repositors  consist  of 
flexible  hollow  tubes  having  a  loop  of  cord  emerging  from  an 
aperture  just  above  the  tip  of  the  tube.  This  loop  of  cord  is 
passed  around  the  umbilical  cord  and  the  loop  then  placed 
over  the  tip  of  the  repositor.  It  is  drawn  sufficiently  tight  to 
hold  the  cord  in  position  and  the  instrument  is  then  passed 
with  the  cord  into  the  uterus  as  high  up  as  possible,  the  grasp 
of  the  instrument  and  cord  relaxed,  and  the  instrument  pulled 
gently  outward,  when  the  cord  slips  over  the  tip  and  the 
umbilical  cord  is  freed  within  the  uterine  cavity.  An  or- 
dinary flexible  good-sized  catheter  may  be  used  as  a  repositor 
in  this  way.  Other  repositors  are  constructed  upon  prac- 
tically this  principle,  some  of  them  containing  a  rod  which 
pushes  out  a  plug  fastened  to  the  end  of  the  retaining  cord. 

If  the  cord  prolapses  during  the  active  stage  of  labor  and 
the  presenting  part  be  on  the  pelvic  floor,  it  is  usually  im- 
possible to  replace  it.  The  obstetrician  must  then  proceed 
to  deliver  as  rapidly  as  the  safety  of  the  mother  will  permit. 

Because  the  loop  of  cord  cannot  be  felt  to  pulsate  it  does 
not  always  follow  that  fetal  death  is  inevitable.  Cases 
are  on  record  where  the  cord  at  the  time  when  it  was  carried 
into  the  uterus  by  the  hand  could  not  be  felt  to  beat,  and  yet 
where  a  living  child  was  afterward  born.  In  these  cases  the 
circulation  of  the  cord  evidently  becomes  re-established  after 
the  cord  is  replaced. 

INFECTION  COMPLICATING  LABOR 

Patients  in  labor  may  become  infected  through  the  care- 
lessness of  those  who  attend  them,  or  because  pathogenic 
bacteria  in  the  vagina  make  their  way  upward  through  the 
cervix  into  the  uterus.  Occasionally  the  amniotic  liquid  is 


INFECTION   COMPLICATING    LABOR  229 

infected  by  bacteria  from  the  intestine  of  the  fetus  before 
labor  begins. 

Signs  and  Symptoms. — Infection  during  labor  produces 
fever  of  varying  degree  and  disturbance  of  the  pulse.  If  the 
infection  remains  localized  in  the  genital  tract  and  does  not 
enter  the  blood  the  temperature  rarely  rises  above  103  Y^  F. 
If  streptococci  enter  the  blood  the  temperature  may  reach 
104°  F.  or  higher.  The  pulse  rate  varies  with  the  severity 
of  the  infection  and  the  resisting  power  of  the  patient.  The 
vaginal  discharge  in  these  cases  is  frequently  foul,  or  if  with- 
out odor  is  dark  red  and  fluid.  The  uterus  may  be  tender 
upon  pressure. 

Pathology. — The  pathology  of  this  condition  consists 
in  the  entrance  of  pathogenic  bacteria  through  small  lacera- 
tions in  the  cervix  or  through  the  decidua  into  the  lymphatics 
and  blood  current  of  the  uterus.  If  bacteria  make  their  way 
into  the  substance  of  the  placenta  the  blood  stream  speedily 
becomes  infected.  If  the  uterus  be  emptied  with  reasonable 
promptness  and  made  to  contract  strongly,  infection  may  be 
limited  to  the  decidua  and  endometrium ;  but  if  labor  with 
infection  be  prolonged  systemic  infection  is  almost  inevitable. 

Diagnosis. — The  diagnosis  of  this  condition  is  made  by 
the  altered  pulse  and  temperature,  the  sensitiveness  of  the 
uterus,  pain  in  the  abdomen,  altered  vaginal  discharge,  and 
constitutional  symptoms  of  infection.  In  severe  cases  chills 
maj'  occur. 

Prognosis. — The  prognosis  of  infection  occurring  during 
labor  is  grave  and  should  always  be  guarded.  It  is  diffi- 
cult to  ascertain  the  precise  infective  agent,  and  usually  the 
infection  is  of  a  mixed  character  and  proceeds  rapidly. 

Treatment. — The  treatment  of  labor  complicated  by  in- 
fection consists  in  terminating  labor  as  rapidly  as  possible 
with  the  least  traumatism  to  the  mother.  If  evidences  of 
severe  infection  be  present  the  infected  uterus  should  be  re- 
moved with  the  fetus. 

If  the  operator  decides  that  the  uterus  should  not  be  sacri- 
ficed, and  partial  dilatation  is  present,  he  may  terminate 
labor  with  the  least  traumatism  to  the  mother.  Unless  the 
head  be  low  down  craniotomy  is  indicated,  with  the  careful 
delivery  of  the  child  through  the  cervix,  dilated  by  the  gloved 


230  MANUAL   OF   OBSTETRICS 

hand  under  ether.  The  removal  of  the  placenta  should  be 
followed  by  copious  irrigation  of  the  uterus  with  hot  1  per 
cent,  lysol,  followed  by  packing  with  10  per  cent,  iodoform 
gauze.  It  is  better  to  avoid  closing  lacerations  in  these  cases 
to  permit  free  drainage  and  to  prevent  the  retention  of  in- 
fected material.  Strychnia  and  ergot  with  digitalin,  should 
be  given  hypodermatically,  and  saline  intravenous  transfusion 
is  of  positive  value. 

If  the  obstetrician  decides  that  the  body  of  the  uterus 
is  infected  and  that  peritonitis  threatens,  the  patient  should 
be  delivered  by  abdominal  section,  followed  by  the  extirpa- 
tion or  resection  of  the  uterus.  Hysterectomy  is  the  more 
practicable  procedure  and  should  be  terminated  by  fasten- 
ing the  stump  at  the  lower  uterine  segment  outside  of  the 
peritoneum.  This  may  be  done  by  the  original  Porro  opera- 
tion, using  a  clamp,  and  leaving  the  clamp  at  the  lower  border 
of  the  abdominal  incision;  or  by  hysterectomy,  stitching  the 
stump  at  the  extremity  of  the  abdominal  incision.  The  life 
of  the  fetus  may  be  disregarded  in  these  cases  as  most  of 
these  children  perish  from  infection. 

After  the  delivery  of  the  patient  her  treatment  is  that 
of  systemic  infection,  especial  attention  being  given  to  keep- 
ing the  uterus  contracted,  if  it  has  been  left,  and  sustaining 
the  general  strength  and  resisting  power  of  the  patient. 

SUDDEN  DEATH  IN  LABOR 

One  of  the  most  tragic  and  hopeless  accidents  of  parturition 
is  the  sudden  death  of  the  mother  during  or  soon  after  labor. 

Etiology. — No  definite  etiology  has  been  made  out  for 
this  occurrence.  Those  circumstances  which  tend  to  pro- 
duce pulmonary  embolus  favor  the  accident,  as  many  of 
these  patients  die  from  pulmonary  embolism;  others  perish 
from  sudden  dilatation  of  the  heart ;  others  from  rupture  of  a 
cerebral  blood  vessel ;  and  in  other  cases  no  anatomical  cause 
can  be  discovered.  Unquestionably  those  conditions  which 
depress  and  weaken  the  mother  during  pregnancy,  and  in- 
fections of  the  respiratory  tract,  such  as  grippe,  predispose  to 
this  occurrence. 

Diagnosis.— Without  premonitory  symptoms,  and  without 
especial  difficulty  in  labor,  the  patient  is  suddenly  seized, 


SUDDEN  DEATH  IN  LABOR  231 

if  pulmonary  embolism  be  present,  with  respiratory  failure, 
the  heart  continuing  to  beat.  Usually  the  patient  rallies 
slightly  and  in  a  few  cases  under  active  stimulation,  may  grad- 
ually recover.  In  most  cases  a  secondary  collapse  is  fatal. 

The  symptoms  of  the  condition  are  sudden  respiratory 
failure  followed  by  the  rapid  development  of  dilatation  of  the 
heart,  and  failure  in  the  heart's  action. 

Prophylactic  Treatment. — The  possibility  of  this  occur- 
rence can  never  be  dismissed  from  the  mind  of  the  obstet- 
rician; hence  it  is  his  duty  to  bring  all  patients  under  his  care 
during  pregnancy  to  labor  in  the  best  possible  general  con- 
dition. In  general,  those  forms  of  treatment  which  are  de- 
pressing, exhausting  and  overwhelming,  should  be  avoided 
during  labor.  Prolonged  and  unnecessary  anesthesia,  large 
doses  of  narcotics  and  depressing  remedies,  the  occurrence 
of  excessive  bleeding,  rapid  and  unskilful  delivery,  extensive 
lacerations,  failure  of  the  uterus  to  contract,  and  great 
mental  and  nervous  shock,  should  all  be  avoided  and  if 
possible  prevented.  Those  patients  who  are  naturally  in- 
clined to  disease  of  the  heart  and  blood  vessels,  and  who  are 
highly  nervous,  are  fit  subjects  for  this  accident. 

Treatment. — The  possibility  of  this  occurrence  makes 
it  imperative  that  the  obstetrician  be  always  prepared  to 
promptly  stimulate  a  parturient  patient.  One  or  two  reli- 
able hypodermatic  syringes,  strychnia,  digitalin,  atropin 
and  adrenalin,  should  all  be  in  readiness  at  every  labor. 
When  in  spite  of  precautions  the  accident  develops,  the  uterus 
must  be  made  to  contract  by  manipulation,  and  stimu- 
lants given  hypodermatically  as  near  the  heart  as  possible. 
Strychnia,  digitalin  and  atropin,  intravenous  transfusions 
with  salt  solution  and  adrenalin,  a  mustard  paste  over  the 
precordium,  the  inhalation  of  ammonia,  should  all  be  used  as 
freely  as  possible.  In  hospital  the  Faradic  current,  one  pole 
beneath  the  cerebellum  and  one  over  the  heart,  is  useful.  If 
the  heart  can  be  made  to  contract  and  a  stimulant  is  forced 
into  the  lung,  the  patient  may  still  recover,  although  embolic 
pneumonia  will  be  inevitable.  Should  the  accident  occur 
before  the  child  has  been  delivered,  and  the  mother  die,  the 
child  must  be  immediately  delivered  in  the  quickest  way 


232  MANUAL   OF   OBSTETRICS 

possible.     Usually   the    forceps    suffices,    but    postpartum 
Cesarean  section  may  be  necessary. 

The  development  of  secondary  shock  within  a  few  hours 
after  the  first  attack  should  always  be  anticipated,  and  es- 
pecially in  cases  where  no  abnormality  in  the  circulatory  ap- 
paratus can  be  detected,  and  where  the  element  of  nervous 
shock  preponderates. 

ECTOPIC  PREGNANCY 

When  the  ovum  attaches  itself  outside  its  usual  location 
within  the  cavity  of  the  uterine  body  the  condition  is  called 
ectopic  pregnancy.  According  to  location  this  may  be  di- 
vided into  upper  and  lower  ectopic  gestation.  In  the  former 
the  impregnated  ovum  may  remain  in  the  Graafian  follicle,  in 
the  Fallopian  tube,  or  in  the  cornu  of  the  uterus,  and  there 
develop  until  rupture  of  its  capsule  results.  In  the  latter 
the  ovum  may  attach  itself  to  the  wall  of  the  uterus  at  the 
lower  uterine  segment,  and  its  attachment  and  placental  de- 
velopment gradually  cover  entirely  or  partially  the  internal 
os  uteri.  This  latter  condition  is  usually  called  placenta 
prsevia. 

Ovarian  Pregnancy. — Clearly  denned  cases  abundantly 
demonstrate  the  possibility  of  this  condition.  Obviously 
the  ovum  can  only  develop  in  the  Graafian  follicle  but  a  short 
time  when  its  attachment  must  extend  to  other  and  neigh- 
boring tissues.  So  the  site  of  the  ovum  would  be  formed  by 
the  Graafian  follicle,  by  decidua  developed  upon  the  surface 
of  the  intestine,  the  broad  ligament,  the  peritoneal  surface 
of  the  uterus,  and  the  omentum  or  mesentery.  Should  the 
anatomical  conditions  be  favorable,  the  ovum  may  form  a 
complete  sac  among  the  intestines  in  the  abdomen,  and  the 
embryo  develop  to  a  fetus  at  or  beyond  viability. 

Diagnosis. — The  diagnosis  of  ovarian  pregnancy  is  im- 
possible without  abdominal  section.  Ectopic  pregnancy  may 
be  recognized  in  these  cases  by  a  sensitive  tumor  where  the 
ovaries  may  be,  which  is  evidently  separate  from  the  uterus. 
The  presence  of  decidua  in  the  uterus  may  be  demonstrated 
by  removing  the  scrapings  and  subjecting  them  to  micro- 
scopic examination. 

The  positive  diagnosis  of  ovarian  pregnancy  is  made  at 


ECTOPIC    PREGNANCY 


233 


section  by  finding  an  ovum  whose  sac  in  part  is  in  the  wall 
of  the  ovary.  If  the  ovary  be  removed  and  subjected  to 
microscopic  section  decidual  cells  can  be  demonstrated  at  the 
site  of  the  Graafian  follicle. 

The  etiology  of  this  condition  is  unknown,  except  in  so 
far  as  it  shares  in  the  etiology  of  ectopic  pregnancy.  Ab- 
normal  position  of  the  ovary  and  fimbriated  extremity  of  the 
Fallopian  tube  through  adhesions  from  previous  inflamma- 
tion, and  abnormal  conditions  of  the  lining  membrane  of  the 
tube,  both  seem  to  have  some  bearing  upon  its  occurrence. 


a 


Fig.  100. — Unruptured  tubal  gestation  with  apoplectic  ovum:  a, 
tube  distended  with  clot;  b,  ovary  in  section;  c,  cyst;  d,  fetus  in  sac  of 
tube,  limbs  protruding. 

Tubal  Ectopic  Pregnancy. — In  this  variety  the  impreg- 
nated ovum  lodges  in  the  Fallopian  tube  and  there  develops. 
If  this  occurs  near  the  fimbriated  extremity,  and  the  tissues 
of  the  tube  be  firm  and  elastic,  and  the  ovum  becomes  large 
enough  to  excite  contractions  of  the  tube  by  pressure,  the 
ovum  may  be  forced  out  through  the  fimbriated  extremity 
into  the  pelvic  or  abdominal  cavity,  constituting  tubal  abor- 
tion. Should  this  not  occur  the  ovum  will  grow  until  the 
distended  tube  can  no  longer  contain  it,  when  rupture  will 
occur.  Occasionally  the  impregnated  ovum  passes  down- 


234 


MANUAL    OF   OBSTETRICS 


ward  after  lodging  in  the  Fallopian  tube,  finally  reaching  the 
uterine  cavity. 


Fig.  101. — Interstitial  pregnancy. 

Cornual  Pregnancy. — -Cornual  ectopic  gestation  comprises 
the  lodging  of  the  impregnated  ovum  in  the  wall  of  the  uterus 
where  the  Fallopian  tube  enters  the  womb.  Such  a  preg- 


ECTOPIC    PREGNANCY 


235 


nancy  can  have  but  a  comparatively  short  duration,  as  the 
tissue  of  the  uterine  wall  will  not  stretch  sufficiently  to  permit 
much  development  in  the  ovum.  Rupture  of  the  cornu 
at  its  external  surface  will  develop  and  the  ovum  will  die 
from  hemorrhage,  or  be  extruded  into  the  pelvic  or  abdominal 
cavity. 

Broad  Ligament  Pregnancy. — In  rupture  of  a  tubal  preg- 
nancy on  the  inferior  surface  of  the  tube  the  impregnated 
ovum  and  blood  clot  may  pass  between  the  layers  of  the 
broad  ligament  and  there  become  practically  encysted.  The 


Fig.  102. — Uterus  and  sac  of  broad  ligament  gestation. 

future  course  of  the  ovum  will  depend  upon  the  possibility 
of  the  gradual  enlargement  of  its  envelope.  Where  the  ovular 
sac  can  separate  the  layers  of  the  broad  ligament  upward 
and  backward  sufficient  room  may  be  obtained  to  permit  the 
development  of  the  ectopic  fetus  to  viability  or  beyond.  If, 
however,  the  conditions  are  such  that  the  ovum  and  its  sac 
are  subjected  to  firm  pressure  the  growth  of  the  ovum  will 
cease  and  it  will  remain  surrounded  by  a  hematoma.  Should 
infection  from  the  adjacent  bowel  or  other  focus  develop, 
pelvic  abscess  may  result. 


236  MANUAL   OF    OBSTETRICS 

Diagnosis. — The  diagnosis  of  early  ectopic  gestation, 
ovarian,  tubal,  cornual,  or  broad  ligament,  if  rupture  has  not 
yet  occurred,  is  often  a  matter  of  difficulty.  If  ectopic 
pregnancy  is  on  the  right  side,  with  pain  and  slight  disturb- 
ance of  pulse  and  temperature,  and  there  is  sensitiveness  on 
palpation,  the  symptoms  may  resemble  those  of  appendicitis 
or  salpingitis  with  exudate.  If  the  pregnancy  be  upon  the 
left  side  it  may  be  confused  with  colitis  and  impacted  feces 
in  the  upper  portion  of  the  rectum. 

The  diagnosis  of  ectopic  pregnancy  in  the  early  months 
when  rupture  occurs  is  more  simple  and  sure.  Sudden  pain 
and  shock  are  the  predominant  symptoms.  Nausea  and 
vomiting  so  often  seen  in  appendicitis  are  often  wanting. 
Peritonitis  may  not  begin  at  once,  and  a  distinctly  defined 
tumor  can  often  not  be  made  out,  but  the  element  of  shock 
and  anemia  is  most  suggestive. 

Where  the  tube  has  ruptured  and  the  ectopic  ovum  has 
developed  to  some  extent  between  the  layers  of  the  broad 
ligament  a  pelvic  tumor  can  be  outlined  on  vaginal  examina- 
tion. This  will  be  somewhat  elastic  and  boggy  to  the  touch 
and  somewhat  sensitive.  The  presence  or  absence  and  the 
degree  of  leukocytosis  should  indicate  the  power  of  the 
patient's  resistance  and  the  possibility  of  infection  and  sup- 
puration. The  pulse  and  temperature  will  indicate  the 
amount  of  hemorrhage  and  the  patient's  resisting  power; 
but  in  ectopic  gestation  cases  are  often  seen  where  a  positive 
diagnosis  is  made  only  after  the  abdomen  has  been  opened. 
The  presence  of  severe  shock  suddenly  would  justify  the 
opening  of  the  abdomen,  if  no  positive  anatomical  diagnosis 
could  be  made  out. 

Etiology.— The  etiology  of  ectopic  gestation,  tubal,  cornual 
and  broad  ligament,  has  been  given  in  treating  of  ovarian 
pregnancy.  A  history  of  previous  salpingitis  is  often  ob- 
tained. In  other  cases  painful  menstruation  and  other 
symptoms  point  to  defective  development  in  the  genital 
tract. 

Prognosis.— In  these  cases  the  prognosis  is  always  doubtful 
and  usually  grave.  While  it  is  true  that  some  cases  will  re- 
cover without  interference  by  the  gradual  cessation  of  bleed- 
ing and  the  absorption  of  the  ovum  and  its  envelope,  in  the 


ECTOPIC    PREGNANCY  237 

majority  a  fatal  issue  is  caused  by  infection,  acute  anemia, 
and  shock.  The  results  of  operation  are  so  far  superior  to 
those  of  non-interference  that  where  operation  is  undertaken 
by  competent  persons  in  good  surroundings,  the  patient's 
chance  is  better  than  by  expectant  treatment. 

Treatment. — These  cases  should  be,  if  possible,  trans- 
ported to  hospital  as  rapidly  as  can  be  done  and  immediately 
subjected  to  section.  On  opening  the  abdomen  the  point  of 
rupture  should  be  sought  as  promptly  as  possible  and  such 
tissue  ligated  as  will  immediately  check  bleeding.  A  bursted 
Fallopian  tube  should  be  removed  and  as  much  blood  clot 
taken  from  the  abdomen  as  the  patient's  condition  will  per- 
mit. If  peritonitis  is  absent  and  the  conditions  have  been 
favorable  for  clean  operation  the  abdomen  may  be  closed 
without  drainage.  If  circumstances  have  been  unfavorable 
for  a  clean  operation,  a  cigarette  drain  or  gauze  bag  should 
be  inserted. 

The  point  of  great  importance  is  the  time  for  operation. 
The  operator  must  delay  sufficiently  long  to  satisfy  himself 
that  the  patient  is  not  reacting  from  the  original  shock.  It 
is  often  possible  to  wait  an  hour  or  two  after  the  rupture  of 
the  envelope  of  the  ovum  until  the  patient  has  recovered 
somewhat.  She  will  then  bear  anesthesia  and  operation 
much  better  than  at  the  moment  of  rupture.  If,  however, 
no  reaction  is  manifest  immediate  operation  becomes  im- 
perative. 

If  the  pregnancy  is  so  far  advanced  that  placental  tissue 
has  developed,  the  operator  should  abstain  from  forcibly 
separating  this  tissue  from  adjacent  parts  to  which  it  has 
adhered.  If  the  placenta  has  in  greater  part  been  formed  and 
does  not  separate  readily  it  should  be  left,  the  cord  ligated 
and  cut  close  to  the  placenta,  the  membranes  sewed  to  the 
edges  of  the  abdominal  incision,  and  the  membranes  tam- 
poned with  10  per  cent,  iodoform  gauze. 

In  broad  ligament  pregnancy  where  hematoma  forms  and 
infection  develops  with  suppuration,  the  abscess  may  often 
be  opened  to  advantage  through  the  vagina.  Free  drainage 
must  be  obtained,  and  a  large  soft  rubber  tube  may  be  inserted 
through  the  vaginal  incision  into  the  abscess,  and  retained  in 
position  by  vaginal  packing  with  gauze. 


238  MANUAL   OF    OBSTETRICS 

Prognosis. — The  prognosis  of  ectopic  gestation  of  the 
varieties  enumerated  depends  upon  the  diagnostic  power  of 
the  practitioner  who  has  the  case,  and  the  skill  and  judgment 
of  the  operator  to  whom  it  is  entrusted.  General  practi- 
tioners should  familiarize  themselves  with  the  signs  and  symp- 
toms of  ectopic  gestation,  and  a  competent  operator  should 
be  called  to  the  case  as  soon  as  possible.  While  an  emer- 
gency operation  for  this  condition  may  be  done  in  the  pa- 
tient's house  her  chance  of  recovery  will  be  greatly  increased 
if  she  can  have  hospital  advantages. 

Abdominal  Pregnancy. — When,  after  rupture  of  ovarian, 
tubal,  cornual  or  broad  ligament  pregnancy,  the  ovum  passes 
upward  into  the  abdominal  cavity,  it  may  engraft  itself  upon 
the  surrounding  omentum,  mesentery,  peritoneum  or  bowel, 
and  gradually  develop  a  placenta  and  membranes,  and  the 
fetus  may  develop  to  viability  or  even  to  full  term.  In  a  few 
cases  the  abdomen  has  been  opened  and  a  living  child  de- 
livered, which  has  survived.  In  the  majority  of  cases  the 
child  dies  through  interference  with  the  placenta,  the  am- 
niotic  liquid  is  absorbed,  and  the  child  becomes  changed  into 
a  waxy  or  calcareous  substance.  In  the  latter  stage  it  is 
known  as  a  lithopsedion.  As  such  it  may  be  retained  indefi- 
nitely in  the  abdomen  of  the  mother  and  may  be  discovered 
only  years  after  its  occurrence  by  post-mortem  examination 
for  some  other  cause. 

Diagnosis. — The  diagnosis  of  abdominal  pregnancy  at 
viability,  with  living  fetus,  is  made  by  hearing  fetal  heart 
sounds,  by  outlining  the  fetal  limbs  and  body,  and  by  making 
out  the  empty  and  slightly  enlarged  uterus.  In  some  cases 
the  fetal  sac  is  adherent  to  the  fundus  of  the  uterus  and  the 
two  cannot  be  differentiated.  The  cervix  uteri,  however, 
does  not  develop  in  proportion  to  the  period  of  gestation, 
and  this  may  serve  as  a  useful  point  in  differential  diagnosis. 
If  the  fetus  dies  within  the  abdomen  of  the  mother  and  the 
amniotic  liquid  is  absorbed  it  will  constitute  a  tumor,  when 
recognition  by  palpation  may  be  possible. 

Treatment. — In  determining  the  treatment  of  a  case  of 
abdominal  pregnancy  heed  must  be  given  to  the  period  of 
gestation  and  to  the  wishes  of  the  parents.  If  the  fetus  is 
just  viable  and  the  mother  is  earnestly  desirous  of  securing  a 


ECTOPIC    PREGNANCY  239 

living  child,  and  is  willing  to  take  the  risk  of  prolonged  gesta- 
tion, the  operator  may  wait  until  viability  is  assured  before 
operating.  If  the  fetus  has  died  there  is  no  reason  for  delay. 

Where  the  patient  does  not  wish  to  regard  the  life  of  the 
fetus  and  there  is  evidence  that  it  still  lives,  the  operator 
may  wait  its  death  to  avoid  the  risk  of  hemorrhage,  which 
inevitably  follows  separation  of  the  placenta  from  the  wall  of 
the  fetal  envelope.  In  these  cases  intermittent  pain  occurs 
which  simulates  uterine  contractions  and  which  is  soon  fol- 
lowed by  the  death  of  the  child.  After  evidence  of  fetal  life 
has  disappeared  the  operator  may  wait  a  few  days,  closely 
watching  the  mother's  pulse  and  temperature,  to  give  time 
for  the  plugging  of  the  vessels  of  the  placenta  and  of  the 
placenta!  decidua. 

At  operation  the  fetus  should  be  removed  with  whatever 
amniotic  liquid  may  be  present.  The  placenta  should  then 
be  sought  but  not  disturbed,  and  the  umbilical  cord  ligated 
and  cut  close  to  the  placenta.  No  effort  should  be  made  to 
remove  the  placenta,  unless  it  be  so  situated  that  it  can  read- 
ily be  separated,  leaving  a  smooth  and  even  surface.  Such 
separation  is  always  dangerous  and  may  be  followed  by  fatal 
hemorrhage. 

Without  disturbing  the  placenta  the  other  contents  of 
the  ovular  sac  should  be  removed  gently  and  the  membranes 
stitched  into  the  lower  portion  of  the  abdominal  incision. 
The  sac  of  the  fetus  should  then  be  tamponed  firmly  with  10 
per  cent,  iodoform  gauze  and  the  end  of  the  gauze  brought 
out  at  the  lower  end  of  the  abdominal  incision.  It  is  often 
advisable  to  use  a  Mickulicz  bag  in  these  cases,  filling  it  with 
strips  of  gauze  until  firm  pressure  is  exerted  upon  the  entire 
fetal  sac. 

After-treatment. — These  patients  require  stimulating  treat- 
ment by  hypodermatic  injection  at  first,  and  then  by  mouth. 
The  gauze  should  be  gradually  removed  and  should  be 
discarded  in  from  ten  to  fourteen  days.  The  placenta  will 
undergo  gradual  necrosis  and  will  be  gradually  discharged 
through  the  abdominal  opening.  After  the  gauze  has  been 
removed  the  sinus  which  remains  should  be  kept  open  by 
inserting  as  nearly  to  the  bottom  as  possible  a  cigarette  drain 
or  strand  of  iodoform  gauze. 


240  MANUAL    OF    OBSTETRICS 

The  recovery  of  these  cases  is  tedious,  because  of  the 
length  of  time  necessary  to  secure  the  removal  of  the  placenta. 
Usually,  however,  complete  recovery  ensues. 

Where  the  fetal  sac  becomes  infected  in  abdominal  preg- 
nancy and  pus  forms,  the  suppurative  process  may  pene- 
trate the  adjacent  tissues  and  open  upon  the  surface  of  the 
skin  or  into  the  bladder  or  rectum.  Thus  in  one  case  a 
patient  with  anomalous  symptoms  noticed  a  discolored  area 
near  the  umbilicus  which  gradually  broke  down  and  through 
which  protruded  the  thigh  bone  of  the  fetus.  This  opening 
was  subsequently  enlarged  and  a  fetal  skeleton  removed 
piecemeal.  In  cases  of  abdominal  or  pelvic  pregnancy  sec- 
ondary to  ovarian  or  tubal,  fetal  bones  have  made  their  way 
into  the  urinary  bladder  or  into  the  rectum. 

The  treatment  of  these  cases  consists  in  cautiously  en- 
larging the  fistulous  opening,  removing  as  much  of  the  con- 
tents of  the  sac  as  possible,  and  keeping  the  fistula  open 
until  the  tract  heals  from  the  bottom. 

Prognosis. — In  abdominal  pregnancy  the  mother's  safety 
depends  upon  the  unruptured  condition  of  the  fetal  sac  and 
the  lack  of  disturbance  by  manipulation  at  operation  with  the 
placenta.  When  a  fatal  issue  occurs  in  these  cases  it  results 
from  infection  or  from  hemorrhage  when  the  placenta  is 
forcibly  detached.  Hence  with  good  management  the  ma- 
jority of  mothers  recover  from  abdominal  pregnancy.  Very 
few  of  the  children  are  born  alive  and  they  are  poorly  nour- 
ished and  developed,  and  few  survive. 

PLACENTA  PILEVIA 

In  this  variety  of  ectopic  gestation  the  impregnated  ovum 
lodges  in  the  lower  uterine  segment  or  in  the  cervix  and  so 
develops  that  in  many  cases  the  placental  substance  covers  a 
portion  or  the  entire  internal  os. 

Etiology. — This  variety  of  ectopic  gestation  occurs  most 
frequently  in  ill-developed  primiparse  or  in  multipart  who 
have  been  weakened  and  in  whom  the  uterus  has  been  fre- 
quently over-distended  by  repeated  gestation.  The  cause 
of  placenta  pravia  is  to  be  found  in  the  condition  of  the  endo- 
metrium  and  in  the  anatomical  condition  and  contour  of  the 
uterus.  If  the  endometrium  be  in  an  abnormal  state,  if  it 


PLACENTA    PH.EVIA 


241 


be  partially  atrophied  or  deficient  in  tone  or  thickness,  the 
ovum  may  gravitate  to  its  abnormal  i>osition.  If  the  uterus 
be  poorly  developed  or  its  muscle  thickened  by  repeated 
parturition  the  impregnated  ovum  will  not  find  the  anatom- 


01 


oe 


Fig.  103. — Placenta  pnevia;  breech  presentation,  prolapse  of  foot:  cr, 
contraction  ring;  oi,  internal  os;  oe,  external  os. 

ical  conditions  favorable  for  a  natural  lodgment  in  the  uter- 
ine body  and  will  gravitate  downward  to  its  abnormal  posi- 
tion. Placenta  praevia  often  accompanies  twin  pregnancy, 
and  in  some  cases  polyhydramnios  is  present. 

16 


242  MANUAL   OF    OBSTETRICS 

Varieties. — This  variety  of  ectopic  gestation  is  commonly 
divided  into  central  or  complete  placenta  prsevia,  where  the 
placenta  completely  covers  the  lumen  of  the  internal  os; 
partial  or  incomplete  placenta  prsevia,  where  some  consider- 
able portion  of  the  internal  os  is  covered  by  placental  sub- 
stance; marginal  placenta  prsevia,  where  the  edge  of  the 
placenta  comes  to  the  edge  of  the  internal  os;  and  lateral 
placenta  prsevia,  where  the  placenta  is  attached  laterally  to 
the  wall  of  the  uterus  throughout  the  greater  portion  of  the 
lower  uterine  segment. 

It  is  evident  that  in  these  cases  the  situation  of  the  placenta 
is  such  that  the  dilatation  of  the  lower  birth  canal  in  the 
early  stages  of  parturition  must  inevitably  separate  the 
placenta  to  a  greater  or  less  extent  from  its  attachment,  and 
thus  produce  more  or  less  hemorrhage. 

Signs  and  Symptoms. — Clinically  speaking,  the  most  sig- 
nificant symptom  of  placenta  prsevia  is  sudden,  bright  hem- 
orrhage from  the  vagina  during  pregnancy  without  pain  or 
without  the  occurrence  of  shock  or  traumatism.  Sometimes 
this  bleeding  occurs  during  or  after  defecation.  In  many 
cases  there  is  no  warning,  and  no  known  cause  for  it.  The 
uterus  does  not  become  sensitive  in  these  cases,  uterine  con- 
tractions do  not  at  first  develop,  there  is  little  if  any  shock, 
and  the  patient  is  often  so  little  affected  by  it  that  she  will 
not  believe  the  obstetrician's  statement  that  the  condition 
is  dangerous. 

On  vaginal  examination  in  placenta  prsevia  the  obstetri- 
cian will  find  increased  temperature  in  the  upper  portion  of 
the  vagina  and  throughout  the  cervix.  The  blood  vessels 
in  this  region  will  pulsate  with  unusual  force.  The  cervix 
is  softened  and  will  usually  admit  at  least  one  finger. 

In  making  this  examination  the  obstetrician  should  note 
the  conditions  of  the  cervix.  In  placenta  prsevia  in  primi- 
parse  and  in  some  multiparse,  the  cervix  is  often  unusually 
soft  and  relaxed.  Dilatation  is  often  present  to  some  degree, 
and  one  or  two  fingers  can  usually  be  inserted.  If  the  pla- 
centa is  central  the  fingers  will  come  against  the  uterine  pla- 
cental surface,  which  gives  to  the  touch  the  feeling  of  raw 
flesh.  If  the  placenta  prsevia  be  not  complete  the  fingers 
will  find  some  area  within  the  internal  os,  where  placental 


PLACENTA    PILEVIA  243 

tissue  is  absent  and  where  the  fingers  come  against  the  fetal 
membranes.  If  the  membranes  have  completely  or  partially 
ruptured,  recognition  of  this  area  is  more  difficult.  Vaginal 
examination  in  placenta  pra3via  is  very  important  and  should 
be  very  gently  made.  A  rough  examination  will  separate 
the  placenta  to  greater  or  less  extent  and  produce  fresh  hem- 
orrhage. Care  and  thoroughness  must  be  exercised  in 
making  this  examination  to  determine  whether  an  interval 
of  membranes  can  be  found  which  can  be  efficiently  ruptured. 
If  this  can  be  done  to  advantage  it  may  be  a  determining 
point  in  the  selection  of  treatment. 

Differential  Diagnosis. — It  is  important  to  distinguish 
placenta  prsevia  from  abortion  in  the  early  months,  and  in  the 
later  months  from  accidental  separation  of  the  normally  im- 
planted placenta.  Many  early  abortions  undoubtedly  re- 
sult from  placenta  prsevia,  but  it  is  difficult  until  the  cervix 
will  admit  a  finger  to  make  the  diagnosis.  The  presence  of 
placenta  praevia  in  the  early  months  will  be  inferred  when 
without  known  cause  the  patient  has  sudden  bright  copious 
hemorrhage. 

In  placenta  praevia  hemorrhage  is  without  known  cause. 
In  accidental  separation  of  the  normally  implanted,  placenta 
the  patient  is  toxemic  or  there  is  a  history  of  a  blow,  a  fall, 
a  kick,  a  sudden  strain,  or  some  other  mechanical  violence  or 
great  disturbance  or  shock.  In  placenta  pravia  the  uterus 
does  not  at  first  contract  and  is  not  painful  upon  pressure. 
In  accidental  separation  of  the  normally  implanted  placenta 
the  uterus  becomes  tense,  hard  and  very  sensitive  and  painful 
to  manipulation.  In  placenta  praevia  the  hemorrhage  is  usu- 
ally bright  in  color  and  often  copious.  In  accidental  sepa- 
ration of  the  normally  implanted  placenta  the  hemorrhage 
is  usually  dark  in  color,  fluid  in  consistence,  and  rarely  is  a 
large  quantity  of  blood  expelled.  In  accidental  separation 
the  blood  may  be  extravasated  and  remain  within  the  uterus. 
In  placenta  praevia  fetal  life  often  continues  in  spite  of  severe 
maternal  hemorrhage.  In  accidental  separation  of  the  nor- 
mally implanted  placenta  considerable  hemorrhage  is  usu- 
ally followed  by  fetal  death. 

Prognosis. — The  prognosis  in  placenta  praevia  depends 
primarily  upon  the  absence  of  infection,  as  the  greatest  num- 


244  MANUAL   OF   OBSTETRICS 

her  of  patients  will  perish  from  this  source.  While  hem- 
orrhage is  dangerous  it  is  rarely  the  sole  cause  of  death  and  is 
principally  important  because  it  predisposes  to  infection. 
In  placenta  praevia  the  life  of  the  child  is  always  in  danger 
and  its  safety  will  depend  upon  its  prompt  delivery.  Cen- 
tral placenta  prsevia  is  most  dangerous  for  mother  and  child, 
because  the  situation  is  such  that  the  uterus  cannot  be  emp- 
tied without  dilating  the  cervix,  and  the  cervix  cannot  dilate 
without  separating  the  placenta.  The  same  is  true  in  vary- 
ing degree  with  other  varieties  of  placenta  prsevia,  hence  all 
cases  of  placenta  prsevia  are  cases  of  separation  of  the  pla- 
centa in  different  degree,  and  all  are  cases  of  an  abnormally 
situated  or  ectopic  placenta,  and  not  of  a  normally  situated 
or  entopic  placenta.  In  no  serious  complication  of  preg- 
nancy does  the  prognosis  depend  so  much  upon  prompt 
and  intelligent  treatment.  A  mismanaged  case  of  placenta 
prsevia  is  almost  inevitably  fatal,  while  with  skilful  care  the 
most  desperate  case  will  often  survive. 

Treatment. — The  treatment  of  placenta  prsevia  should 
under  all  circumstances  be  conducted  with  the  same  surgical 
appliances,  technique,  and  surroundings  which  are  given  to 
the  other  varieties  of  ectopic  gestation.  Such  cases  should 
be  immediately  transported  to  hospital  upon  the  occurrence 
of  the  first  hemorrhage.  Vaginal  examinations  should  be  as 
infrequent  and  as  carefully  made  as  possible  and  under  thor- 
ough aseptic  precautions.  No  substance  should  be  intro- 
duced within  the  vagina,  and  the  patient  should  be  kept  a 
clean  surgical  case  with  scrupulous  care. 

In  hospital  cases  a  careful  examination  should  be  made 
as  gently  as  possible  with  the  gloved  hand,  under  antiseptic 
precautions.  If  mother  and  child  are  proportionate  in  size, 
the  head  or  breech  presenting  in  a  favorable  position,  and 
a  portion  of  the  membranes  can  be  found  available  for 
rupture,  the  membranes  should  be  torn  as  completely  as 
possible  and  as  much  amniotic  liquid  allowed  to  escape  as  is 
possible.  The  action  of  the  uterus  should  then  be  stimulated 
by  Tffth  grain  of  strychnia  hypodermatically,  and  15  to  30 
minims  of  an  aseptic  preparation  of  ergot  injected  hypo- 
dermatically. This  will  cause  the  uterus  to  act  and  force 
the  fetus  down  against  the  placenta,  preventing  hemorrhage. 


PLACENTA    PILEVIA 


245 


If  the  patient  suffers  severely  from  such  uterine  contractions, 
24  grain  of  coclein  may  be  given  hypodermatically  with  the 
strychnia,     She  should  be  kept  quiet,  the  external  genital 
organs  thoroughly  made  aseptic,  and  sterile  vulvar  dressings 
should  be  worn.    The  patient  should  be  closely  watched.    The 
bladder  should  be  emptied  at  regular  intervals  by  catheter. 
In  these  cases  uterine  contractions  will  gradually  open 
the  cervix  and  press  the  fetus  down,  carrying  the  placenta 
to  the  side,    and   prevent- 
ing hemorrhage.     No  effort 
should   be   made   to  with- 
draw the  fetus  rapidly,  and 
fetal   life  should   be  disre- 
garded ^in  the  interests  of 
the   mother.      When    it    is 
evident  that  the  presenting 
part  has  reached  the  pelvic 
floor  and  is  distending  the 
perineum,  if   the   mother's 
strength   becomes  lessened 
she  may  be  delivered   by 
forceps   or  manual   breech 
extraction.      The   obstetri- 
cian must  be  prepared  un- 
der aseptic  precautions  to 
follow  the  delivery  of  the 
fetus  by  the  removal  of  the 
placenta,  copious  irrigation 
of  the  uterus  with  hot  salt 
solution,  or  1  per  cent,  lysol, 
and  firm  tamponing  with  10 
per  cent,   iodoform  gauze. 

Lacerations  of  the  cervix,  which  often  occur  in  these  cases, 
should  be  immediately  repaired  by  suture.  If  the  mother's 
condition  be  good  and  post-partum  bleeding  does  not  occur, 
laceration  of  the  pelvic  floor  and  perineum  may  also  be  re- 
paired. If  the  patient  is  weak  and  there  is  a  tendency  to  post- 
partum  bleeding,  such  lacerations  should  be  left.  The  vagina 
should  be  tightly  packed  with  sterile  or  bichloride  gauze,  care 
being  taken  to  tampon  firmly  about  the  cervix,  and  a  copious 


Fig.  104. — Placenta  prsevia; 
introducing  a  dilating  bag  in  for- 
ceps through  the  membranes  to 
compress  the  placenta  and  dilate 
the  cervix  (after  Liepmann). 


246  MANUAL   OF   OBSTETRICS 

and  sterile  external  vulvar  dressing  should  be  applied,  pressure 
being  made  over  the  vulva ;  and  permanent  uterine  contraction 
should  be  procured  by  the  hypodermatic  use  of  strychnia  and 
ergot.  Should  sudden  relaxation  occur,  from  1  to  1.5  cc.  of 
pituitrin  given  hypodermatically  will  usually  cause  prompt 
contraction.  If  the  patient  be  anemic,  intravenous  saline 
transfusion  will  be  of  value.  Warmth  beneath  the  cere- 
bellum and  upon  the  surface  of  the  body,  absolute  rest,  and 
oxygen,  are  indicated.  If  by  careful  examination  the  cervix 
is  dilated  only  sufficiently  to  permit  the  entrance  of  one  finger, 
and  no  satisfactory  point  of  rupture  can  be  made  out  where 
the  membranes  can  be  opened,  the  patient  should  be  im- 
mediately delivered  by  abdominal  Cesarean  section.  Vag- 
inal Cesarean  section  is  not  indicated  in  placenta  pravia 
because  the  cervix  and  lower  segment  are  enormously  vascu- 
lar, and  profuse  and  possibly  fatal  hemorrhage  would  occur. 
Abdominal  Cesarean  section  in  these  cases  is  done  in  the 
manner  described  in  treating  of  the  operation. 

It  is  interesting  to  observe  that  hemorrhage  ceases  im- 
mediately upon  emptying  the  uterus  through  the  abdomen. 
After  this  the  womb  should  be  irrigated  by  hot  salt  solution 
poured  from  above,  and  thoroughly  packed  with  10  per 
cent,  iodoform  gauze,  the  end  of  the  gauze  being  carried 
through  the  cervix.  After  the  uterus  and  abdomen  have 
been  closed  in  the  usual  manner  the  vagina  should  be  sponged 
out  with  bichloride  solution  and  firmly  packed  with  bichlor- 
ide gauze.  During  the  operation  intravenous  saline  trans- 
fusion should  be  given  and  hypodermatic  stimulation  of 
strychnia,  atropin,  ergot  and  digitalin,  administered. 

In  cases  of  ectopic  gestation  of  the  variety  called  placenta 
praevia  which  cannot  be  taken  to  hospital,  and  which  must 
be  treated  in  private  houses,  the  mortality  and  morbidity 
are  inevitably  increased  and  the  responsibilities  and  diffi- 
culties greater.  The  practitioner  must  keep  in  mind  the 
cardinal  point  to  conduct  the  case  with  scrupulous  antiseptic 
precautions  and  with  the  least  possible  vaginal  interference. 
Another  point  of  great  importance  is  the  prompt  treatment 
of  the  case  when  the  first  hemorrhage  occurs.  Such  cases 
cannot  be  left  without  continuous  observation,  and  danger 
is  never  over  until  the  uterus  has  been  emptied  and  is 


PLACENTA    PILEVIA 


247 


thoroughly  tamponed,  the  cervical  lacerations  repaired,  the 
vagina  tamponed,  and  the  patient  given  appropriate  general 
treatment. 

In  conducting  a  case  in  a  private  house  the  obstetrician 
requires  the  aid  of  other  competent  obstetricians  or  assist- 
ants, and  a  nurse  or  nurses  trained  in  antiseptic  methods. 


Fig.  105. — Central  placenta pnevia.     Braxton-Hicks  version;  bringing 
foot  of  the  child  through  the  placenta  (after  Liepmann). 

If  upon  examination  the  placenta  is  found  not  to  cover 
completely  the  internal  os,  but  an  area  of  membranes  can 
be  made  out,  the  cervix  should  be  very  gently  and  carefully 
dilated  at  this  point  and  the  membranes  torn  as  thoroughly 
as  possible,  allowing  the  free  escape  of  amniotic  liquid.  The 
case  should  then  be  treated  in  the  manner  already  described, 
care  being  taken  to  introduce  nothing  within  the  vagina  ex- 


248 


MANUAL   OF   OBSTETRICS 


cept  the  fingers  of  the  gloved  hand,  and  under  antiseptic  pre- 
cautions. Before  rupturing  the  membranes  it  is  well  to  irri- 
gate the  vagina  very  gently  with  1  per  cent,  lysol.  The 
obstetrician  or  his  assistants  must  remain  in  constant  at- 
tendance upon  the  patient  until  labor  develops  and  the  case 

can   be    terminated    in    the 
manner  described. 

It  is  of  especial  importance 
in  private  houses  that  an 
obstetric  anesthetize!'  should 
conduct  the  anesthesia  and 
assist  in  the  treatment  of  the 
patient  at  the  time  of  deliv- 
ery. The  general  practitioner 
is  not  competent  to  do  this. 

If  in  a  case  conducted  in 
a  private  house  the  obstetri- 
cian can  find  no  space  avail- 
able for  the  rupture  of  the 
membranes  he  must  then 
cautiously  dilate  the  cervix 
sufficiently  to  enable  him  to 
introduce  the  hand  within 
the  vagina,  to  pass  several 
fingers  through  the  cervix, 
tearing  through  the  placenta! 
substance  and  catching  and 
bringing  down  a  foot  of  the 
fetus.  This  procedure  re- 
quires skill,  experience  and 
judgment,  and  if  improperly 


Fig.  106. — Central  placenta 
pravia;  foot  brought  down  by 
Braxton  -  Hicks  method;  breech 
compressing  the  placenta  (after 
Liepmann). 


performed  may  separate  a 
considerable  placental  area 
and  bring  on  profuse  hemor- 
rhage. It  is  unsafe  to  tear 

through  the  placenta  with  a  hard  or  sharp  instrument,  as  the 
fetus  may  be  severely  wounded,  and  the  mother's  uterus  may 
be  ruptured.  The  foot  should  be  gently  but  firmly  drawn 
downward  until  the  breech  enters  the  pelvic  brim,  and  the 
foot  is  near  the  vulva  or  protrudes  from  it.  A  loop  of  soft 


PLACENTA    PILEVIA  249 

bandage  should  then  be  passed  about  the  foot  so  that  trac- 
tion can  be  made  upon  it.  If  the  foot  shows  a  tendency  to 
recede,  a  weight  of  several  pounds  may  be  attached  to  the 
bandage  to  hold  the  breech  firmly  in  the  pelvic  brim  and 
against  the  placenta. 

Having  effected  this,  the  obstetrician  should  absolutely 
desist  from  further  effort  at  delivery.  The  external  parts 
should  be  thoroughly  cleansed  again  with  antiseptic  fluids, 
the  fetal  leg  wrapped  in  sterile  or  antiseptic  gauze,  and  the 
patient  should  be  given  small  or  moderate  doses  of  strychnia 
and  digitalin  hypodermatically.  If  she  suffers  much  pain 
codein  in  J^  to  %  grain  doses  may  be  added  to  the  strychnia. 
The  bladder  should  be  frequently  emptied  by  catheter  and 
the  patient  should  receive  such  general  stimulation  as  may  be 
required. 

This  procedure  should  control  hemorrhage  and  no  effort 
should  be  made  to  hasten  the  patient's  delivery.  Such  tonic 
or  stimulation  treatment  as  is  needed  may  be  given  and 
the  patient  should  be  constantly  watched  for  signs  of  de- 
veloping labor.  If  she  is  restless  and  apprehensive,  a  mod- 
erate dose  of  morphia  hypodermatically,  with  alcoholic 
stimulus,  will  usually  induce  refreshing  sleep. 

When  the  uterus  begins  to  act  and  the  child  is  gradually 
expelled  precautions  must  be  taken  to  have  ready  stimulants, 
antiseptic  gauze,  and  materials  for  irrigation  and  for  closing 
lacerations.  Partial  anesthesia  may  be  necessary  should  the 
patient  struggle  and  become  unmanageable  as  the  head  is  de- 
livered. The  child  should  be  delivered  as  slowly  and  gently 
as  possible,  an  assistant  following  down  the  uterus  with  the 
hand.  The  placenta  should  then  be  expressed  and  the 
uterus  thoroughly  irrigated  with  hot  normal  salt  solution  or 
1  per  cent,  lysol.  A  firm  packing  of  10  per  cent,  iodoform 
gauze  should  be  inserted  and  the  cervix  should  be  inspected 
for  lacerations.  If  these  are  present,  and  if  hemorrhage  is 
occurring,  they  should  immediately  be  closed  with  No.  2 
chromicized  catgut.  The  vagina  should  then  be  sponged 
out  with  an  antiseptic  solution,  and  if  the  pelvic  floor  and 
perineum  are  lacerated,  and  the  patient'.s  condition  permits, 
such  lacerations  should  be  closed.  If  suture  is  not  per- 
missible they  should  be  left,  but  thoroughly  irrigated  with 


250  MANUAL   OF   OBSTETRICS 

1  per  cent,  lysol.  The  vagina  should  be  firmly  packed  with 
bichloride  gauze,  especial  attention  being  paid  to  packing 
about  the  cervix  so  as  to  make  pressure  against  the  vessels 
of  the  lower  uterine  segment. 

In  these  cases  secondary  relaxation  with  shock  may  de- 
velop within  the  first  twenty-four  hours.  Preparations  should 
be  made  to  combat  this;  strychnia  and  digitalin  should  be 
available  for  hypodermatic  use,  with  morphia  and  atropin. 
To  maintain  a  tonic  condition  of  the  uterus  a  broad  pad  should 
be  placed  across  the  abdomen  above  the  fundus  and  pressure 
made  upon  the  entire  abdomen  by  a  many  tailed  bandage. 
The  urinary  bladder  should  be  frequently  emptied  spontane- 
ously or  by  catheter.  Strychnia,  digitalin  and  ergot,  are  re- 
quired at  regular  intervals  in  moderate  doses.  For  sudden 
relaxation  pituitrin  hypodermatically  will  be  found  useful. 
If  severe  shock  with  relaxation  develops,  the  Faradic  current 
with  one  pole  beneath  the  cerebellum  and  the  other  over  the 
uterus  is  a  most  efficient  and  valuable  stimulant. 

The  Puerperal  Period  in  Placenta  Praevia. — The  gauze 
should  be  removed  in  from  forty-eight  to  seventy-two  hours 
and  one  thorough  but  very  gentle  irrigation  of  the  uterus  and 
vagina  given  with  1  per  cent,  lysol.  No  other  irrigation 
should  be  used.  Strychnia  and  ergot  will  be  found  useful 
during  the  puerperal  period,  with  iron,  arsenic  and  gentian, 
if  the  patient  is  anemic.  If  it  has  been  impossible  to  close 
lacerations  at  the  moment  of  labor,  and  the  patient's  condi- 
tion greatly  improves,  tears  in  the  pelvic  floor  and  perineum 
may  be  sutured  in  from  two  to  three  days  after  labor,  after 
the  gauze  has  been  removed.  If  wounded  surfaces  have 
glazed  over  they  may  be  scraped  with  a  blunt-edge  until  they 
ooze  slightly.  Abundant  liquid  nourishment,  fresh  air,  and 
attention  to  digestion  and  assimilation,  are  required  in  these 
cases.  If  the  child  survives,  it  may  nurse  the  mother  so 
soon  as  she  has  reacted  and  is  evidently  free  from  infection. 

Frequency,  Mortality  and  Morbidity. — It  is  estimated  that 
central  placenta  prsevia  is  present  in  one-fourth  of  all  cases 
of  placenta  prsevia,  and  among  multiparse  more  constantly 
than  primiparse.  There  is  a  possibility  of  its  recurrence  in 
the  same  individual  in  one  case  in  14.  It  occurs  not  infre- 
quently with  twin  pregnancy,  and  polyhydramnios  is  often 


PLACENTA   PILEVIA  251 

present  in  these  cases.  Many  of  the  less  important  forms  of 
placenta  praevia  are  not  diagnosticated  and  are  thought  to 
be  moderate  post-partum  hemorrhage,  or  possibly  bleeding 
from  the  lacerated  cervix  before  delivery  actually  occurs. 

The  mortality  of  placenta  praevia  is  highest  in  the  central 
variety.  From  20  to  30  per  cent,  can  be  taken  as  an  average 
with  fairly  good  treatment.  Where  these  cases  are  taken  in 
hand  after  the  first  hemorrhage,  under  antiseptic  precautions, 
the  maternal  mortality  may  be  reduced  to  from  10  to  20  per 
cent.  In  proportion  as  treatment  is  prompt,  antiseptic  and 
surgical,  the  maternal  mortality  decreases.  Thus  in  18 
cases  of  placenta  praevia  in  which  the  greater  portion  of  the 
os  was  covered  by  placenta,  and  in  which  the  patients  were 
treated  by  abdominal  Cesarean  section  by  the  writer,  all 
mothers  recovered ;  three  of  these  were  exsanguinated  at  the 
time  of  operation. 

The  mortality  of  placenta  praevia  is  highest  in  cases  sub- 
jected to  tamponing  and  attempted  forcible  dilatation  of  the 
cervix  in  private  houses  at  the  hands  of  unskilled  operators. 
In  other  varieties  of  placenta  praevia  than  central,  the  ma- 
ternal mortality  should  not  exceed  6  or  7  per  cent. 

The  fetal  mortality  in  central  placenta  praevia  is  at  least 
90  per  cent.  In  all  varieties  there  is  an  average  of  60  per  cent. 

The  fact  that  placenta  praevia  is  attended  by  hemorrhage 
and  the  frequent  development  of  septic  infection  gives  it  a 
high  rate  of  mortality.  From  10  to  20  per  cent,  is  considered 
an  average. 

Placenta  Praevia  in  the  Early  Months  of  Gestation  Com- 
plicated by  Infection. — When  a  patient  in  the  early  months 
of  pregnancy  has  severe  and  repeated  hemorrhages  and  be- 
comes infected,  her  safety  may  demand  the  complete  re- 
moval of  the  uterus  unopened.  On  section  many  of  these 
are  found  to  be  cases  of  placenta  praevia.  In  these  patients 
the  septic  uterus  is  considered  as  malignant,  and  the  treat- 
ment is  based  upon  the  line  of  reasoning  which  suggests  the 
complete  removal  of  the  cancerous  uterus. 

Prophylactic  Treatment. — While  it  is  difficult  to  describe 
a  direct  line  of  prophylactic  treatment  in  this  variety  of 
ectopic  gestation,  it  is  obvious  that  the  prevention  and  cure 
of  chronic  endometritis,  the  maintenance  of  the  uterus  in  its 


252  MANUAL   OF   OBSTETRICS 

normal  position  and  in  a  healthy  condition,  and  the  avoid- 
ance of  rapidly  repeated  and  exhausting  child-birth,  may  be 
of  value  in  preventing  placenta  prsevia. 

The  diagnosis  of  this  condition  in  the  early  months  of  preg- 
nancy might  lead,  after  consultation,  to  the  prophylactic 
emptying  of  the  uterus  and  the  termination  of  pregnancy  in 
the  interests  of  the  mother. 

MULTIPLE  PREGNANCY 

By  this  term  is  meant  the  presence  in  the  uterus  at  one 
time  of  more  than  one  impregnated  ovum.  This  definition 
must  now  be  revised  to  include  cases  where  one  impregnated 
ovum  is  present  outside  the  uterus  and  one  within  the  womb. 
Cases  have  been  observed  where  twin  pregnancy  was  present, 
one  gestation  being  ectopic,  the  other  entopic. 

Twin  Pregnancy. — Twin  entopic  pregnancy  is  the  most 
common  form  of  multiple  gestation.  If  both  embryos  are 
developed  from  one  ovum  they  are  called  uniovular,  and  the 
sex  is  usually  the  same.  If  two  ova  are  impregnated  at  the 
same  time,  or  with  only  a  brief  interval,  the  sex  is  usually 
different.  Uniovular  twins  usually  have  one  placenta  and 
two  amniotic  sacs  separated  by  a  partition.  Twins  from 
two  ova  may  have  separate  placentae  situated  near  each 
other,  and  possibly  joined  at  the  edge. 

Etiology. — There  is  no  definite  cause  for  twin  pregnancy, 
but  its  tendency  is  hereditary.  Thus  the  women  of  some 
families  produce  twin  children,  and  in  the  same  line  the  same 
tendency  is  sometimes  transmitted.  Twins  happen  more  fre- 
quently in  multipart  or  in  primiparse  above  the  average  age 
of  childbirth. 

Location  and  Development. — When  twin  pregnancy  is 
entopic  one  child  is  usually  in  head  presentation,  first  posi- 
tion, the  other  in  breech  presentation,  second  position.  In 
this  way  the  bulk  of  the  children  is  best  accommodated  in  the 
uterus.  Where  twin  pregnancy  is  entopic  and  ectopic,  the 
ectopic  embryo  may  be  in  any  portion  of  the  genital  tract 
outside  the  uterus.  In  the  most  frequent  forms  of  entopic 
twin  pregnancy  two  fetal  heads  may  sometimes  be  made 
out,  one  at  the  pelvic  brim,  one  at  the  fundus;  and  two  heart 

!f>fius  a-i 


MULTIPLE    PREGNANCY  253 

sounds,  one  on  the  left  side  below  the  umbilicus,  the  other 
on  the  right  side  above  the  umbilicus. 

If  the  patient's  abdominal  wall  be  unusually  thick  and  if 
polyhydramnios  be  present,  it  may  be  impossible  to  diag- 
nosticate twin  pregnancy  until  one  child  has  been  born  and 
the  hand  is  introduced  within  the  uterus.  The  abdomen 


Fig.  107. — Twin  pregnancy  (after  Liepmann). 

is  larger  in  size  than  normal,  the  sensation  of  weight  and 
heaviness  is  greater,  and  pregnancy  rarely  goes  to  full  term 
with  twins. 

Diagnosis. — Twin  pregnancy  may  be  suspected  when 
the  abdomen  at  six  or  seven  months'  gestation  is  unusually 
large.  If  on  careful  examination  two  heart  sounds  can  be 
distinctly  isolated,  or  if  two  heads  can  be  distinctly  pal- 


254  MANUAL   OF    OBSTETRICS 

pated,  a  provisional  diagnosis  may  be  made.  The  physician 
should  anticipate  premature  labor,  and  preparations  for  birth 
should  be  made  at  least  three  weeks  earlier  than  full  term. 

Treatment. — During  pregnancy  the  mother  of  twins 
should  be  kept  in  the  best  possible  general  condition.  As 
the  uterus  is  over-distended  it  will  not  contract  promptly 
unless  the  patient's  muscular  and  nervous  system  is  vigorous. 
Labor  often  begins  by  premature  rupture  of  the  membranes, 
and  when  this  happens  the  patient  should  be  kept  in  bed  with 
sterile  vulvar  dressings  so  that  the  cervix  may  soften  gradu- 
ally, and  thus  give  the  best  possible  chance  for  preserving 
fetal  life.  At  the  moment  of  birth  a  skilled  assistant  should 
be  in  attendance  to  administer  anesthesia  and  to  watch  the 
condition  of  the  uterus  and  ensure  good  contraction.  Should 
labor  delay  and  the  mother  become  tired,  she  should  be  given 
a  small  dose  of  morphia  to  secure  rest.  If  labor  does  not  pro- 
ceed after  this  a  tonic  dose  of  strychnia  may  be  given,  and  if 
the  os  is  more  than  half  dilated  the  membranes  should  be  rup- 
tured. The  birth  of  the  first  twin  usually  follows  without 
much  delay.  When  the  first  child  has  been  born  and 
breathes  well,  its  cord  should  be  tied  and  cut  and  the  child 
removed.  The  gloved  hand  should  then  be  introduced  to  as- 
certain the  presence  of  a  second  child,  and  its  position  and 
presentation.  Usually  the  membranes  of  the  second  twin 
are  found  unruptured.  Its  bag  of  waters  should  be  ruptured, 
with  the  hope  that  the  head  of  the  second  child  will  present. 
If  an  anomalous  presentation  develops,  the  gloved  hand  should 
again  be  introduced  and  podalic  version  performed,  and  the 
second  child  delivered  promptly. 

No  haste  should  be  used  in  delivering  the  placentae,  and 
some  opportunity  should  be  given  for  the  separation  of  the 
placentae  and  the  closure  of  the  uterine  sinuses.  Strychnia 
and  ergot  are  valuable  given  hypodermatically  so  soon  as 
the  children  are  delivered.  If  within  a  half  hour  the  placenta 
cannot  be  expressed,  the  gloved  hand  may  be  introduced  and 
the  placentae  removed,  with  the  membranes  and  other  uter- 
ine contents.  The  uterus  should  then  be  thoroughly  irri- 
gated with  hot  1  per  cent,  lysol  or  salt  solution,  and  firmly 
packed  with  10  per  cent,  iodoform  gauze.  Lacerations  of  the 
cervix  rarely  require  suture  in  these  cases  as  the  children  are 


MULTIPLE    PREGNANCY  255 

smaller  than  the  average.  Should  lacerations  be  present 
and  bleed,  the  torn  cervix  should  be  closed  with  chromicized 
catgut.  Such  stimulation  as  the  patient  needs  must  be  given, 
and  especial  care  is  required  to  secure  prompt  and  permanent 
contraction  of  the  uterus.  The  gauze  packing  may  be  re- 
moved in  from  forty-eight  to  seventy-two  hours,  and  the 
uterus  and  genital  tract  thoroughly  but  very  gently  irrigated 
with  1  per  cent,  lysol. 

Convalescence. — Convalescence  from  twin  birth  will  be 
retarded  by  subinvolution,  anemia  and  exhaustion  conse- 
quent upon  the  effort  to  nurse  two  children.  Subinvolution 
may  be  avoided  by  the  antiseptic  conduct  of  labor,  the  re- 
pair of  lacerations,  and  the  use  of  tonics,  with  small  doses  of 
ergot.  Few  mothers  can  nurse  both  children  at  once,  but 
many  can  care  for  both  during  the  day,  and  night  feeding  of 
cow's  milk  may  be  used  to  complete  the  nourishment.  The 
children  should  nurse  alternately,  and  may  require  additional 
care  in  the  first  weeks  of  life. 

Twin  Pregnancy,  Entopic  and  Ectopic. — Where  twin  preg- 
nancy is  both  entopic  and  ectopic,  the  ectopic  pregnancy  must 
be  removed  so  soon  as  discovered.  Should  this  not  be  done, 
there  is  danger  that,  when  labor  comes  on,  the  sac  of  the  ec- 
topic pregnancy  might  be  ruptured  and  bleeding  follow. 
The  removal  of  the  ectopic  pregnancy  need  not  interrupt  the 
entopic.  If  the  entopic  pregnancy  terminates  before  the 
discovery  of  the  ectopic  gestation,  the  latter  should  be  re- 
moved at  the  conclusion  of  labor  if  the  patient  is  in  good  con- 
dition ;  and  if  not,  so  soon  after  as  possible.  There  is  always 
risk  with  manipulation  and  disturbance  incident  to  uterine 
contractions,  and  the  delivery  of  the  fetus  may  rupture  the 
sac  of  the  ectopic  ovum. 

Pregnancy  Other  Than  Twin. — Pregnancy  with  triplets, 
although  rare,  has  been  observed  once  in  between  2000  and 
3000  births,  and  once  in  8000  births.  The  statistics  of  a 
number  of  countries  show  that  triplets  occur  once  in  6558 
births.  Quadruplets  have  been  observed  once  in  307,000 
births.  The  greatest  number  of  impregnated  ova  known 
to  have  been  in  the  uterus  at  one  time  is  those  in  a  case  of 
sextuplets,  of  which  the  specimen  is  preserved  in  one  of  the 
Italian  museums. 


256  MANUAL   OF   OBSTETRICS 

Diagnosis. — The  exact  diagnosis  of  multiple  pregnancy 
other  than  twin  is  rarely  made  until  labor.  Even  then  their 
presence  is  unsuspected  until  with  the  birth  of  two  children 
the  uterus  still  remains  large.  The  introduction  of  the  hand 
reveals  the  presence  of  the  third. 

Course  of  Pregnancy. — Pregnancy  rarely  goes  so  far  as 
with  twins  because  of  the  greater  distention  of  the  uterus. 
Labor  is  often  tedious  because  of  inefficient  uterine  contrac- 
tions, and  frequently  the  services  of  a  physician  are  required 
to  deliver  the  child.  The  tendency  to  relaxation  and  hem- 
orrhage are  greater  and  additional  precautions  are  necessary. 
Delivery  itself  is  not  difficult,  and  podalic  version  with  ex- 
traction is  the  method  usually  employed.  The  children  are 
often  ill-developed  and  poorly  nourished,  and  require  unusual 
care  after  birth. 

HEMORRHAGE   COMPLICATING   PREGNANCY,   LABOR,   AND 
THE  PUERPERAL  PERIOD 

Hemorrhage  is  always  a  serious  complication  because  it 
weakens  the  patient  and  often  makes  manipulation  necessary, 
which  exposes  the  patient  to  additional  risk  of  septic  infec- 
tion. 

Accidental  Separation  of  the  Normally  Implanted  Pla- 
centa.— This  accident  is  sometimes  described  as  concealed 
accidental  hemorrhage  because  the  blood  may  clot  within 
the  uterus  and  but  little  escape  externally. 

Etiology. — Conditions  'of  the  endometrium  which  give 
the  embryo  a  feeble  attachment  predispose  to  placental  sepa- 
ration. Altered  states  of  the  blood,  like  toxemia,  produce 
the  same  result.  Mechanical  injury,  as  in  a  fall,  a  blow,  a 
kick,  a  sudden  strain,  or  rapid  and  sudden  motion,  is  a  fre- 
quent cause.  The  umbilical  cord  coils  about  the  fetus  so 
that  it  becomes  unduly  short  and  may  make  traction  upon 
the  placenta. 

Signs  and  Symptoms. — The  course  of  this  accident  will 
depend  somewhat  upon  the  site  of  the  placental  separation 
and  the  care  which  the  patient  receives.  Where  separation 
is  at  the  lower  border  of  the  placenta — that  nearest  the  os — 
the  blood  will  escape  from  the  placenta  and  make  its  way  be- 
tween the  membranes  and  the  uterine  wall  and  issue  through 


HEMORRHAGE   COMPLICATING   PREGNANCY  257 

the  cervix.  The  blood  is  not  retained  in  these  cases,  the 
presence  of  hemorrhage  gives  warning,  and  therefore  the 
case  is  more  favorable  for  the  patient  than  other  varieties 
of  this  condition. 

If,  however,  placental  separation  occurs  at  the  upper  por- 
tion of  the  placenta  extravasated  blood  will  clot  between  the 
placenta  and  the  uterine  wall;  this  clot  will  act  as  a  foreign 
body,  irritating  the  uterine  muscle  to  contract,  and  by  its 
gradual  increase  will  gradually  separate  the  placenta  from 
the  wall  of  the  uterus.  This  blood  will  be  retained  often- 
times in  clotted  masses,  not  reaching  the  cervix  until  the 
uterus  has  begun  to  contract  or  the  membranes  rupture. 

The  presence  of  clotted  blood  within  the  uterus  excites 
tonic  uterine  contraction.  The  womb  becomes  hard,  very 
sensitive  to  pressure,  and  fetal  heart  sounds  cannot  be  heard 
nor  can  fetal  movements  be  felt.  The  patient's  pulse  and 
temperature  rise  somewhat  and  she  is  often  restless,  and 
gradually  begins  to  complain  of  air  hunger.  If  there  is  slight 
vaginal  hemorrhage  this  ceases  when  she  lies  down,  and  the 
patient  will  frequently  avoid  sending  for  medical  aid  because 
bleeding  stops  when  she  reclines,  and  she  imagines  from  this 
occurrence  that  she  is  safe.  When  sufficient  blood  accumu- 
lates in  the  uterus  to  bring  about  increased  uterine  action 
labor  gradually  develops,  and  when  the  fetus  has  been  ex- 
pelled or  removed  a  mass  of  blood  clot  with  a  partly  or  wholly 
separated  placenta  is  found  within  the  womb.  Sudden  and 
often  fatal  shock  may  follow  the  emptying  of  the  uterus,  and 
patients  may  die  of  exhaustion  or  pulmonary  embolism.  The 
necessity  for  manipulation  and  the  hemorrhage  expose  the 
patient  to  added  risk  of  infection. 

Diagnosis. — When  a  pregnant  patient  complains  of  pain 
in  the  uterus  and  abdomen  with  slowly  but  steadily  rising 
pulse  and  with  some  vaginal  discharge  of  blood,  accidental 
separation  of  the  normally  implanted  placenta  may  be  sus- 
pected. The  character  of  the  hemorrhage  is  of  practical  im- 
portance, for  in  accidental  separation  the  blood  is  rarely 
bright  in  color,  but  dark  and  sometimes  coffee-ground  in 
appearance.  As  hemorrhage  slowly  but  gradually  increases 
the  mother's  pulse  becomes  more  rapid,  weak  and  com- 
pressible, she  complains  of  air  hunger  and  is  restless,  the 


258  MANUAL   OF   OBSTETRICS 

uterus  which  has  been  painful  gradually  relaxes,  and  the  tone 
of  the  uterine  muscle  is  completely  lost.  Patients  may  die 
undelivered,  or  perish  soon  after  birth  from  exhaustion  and 
acute  anemia. 

The  differential  diagnosis  between  placenta  prsevia  and 
accidental  separation  of  the  normally  implanted  placenta 
has  already  been  given.  In  early  gestation  many  cases  of 
abortion  result  from  this  accident  and  confusion  in  diagnosis 
might  arise  between  this  condition  and  ectopic  gestation. 

Treatment. — If  such  cases  are  left  without  interference 
and  the  woman  be  healthy,  and  but  slight  separation  has  oc- 
curred as  the  result  of  mechanical  causes,  if  the  patient  be 
put  at  absolute  rest  separation  and  hemorrhage  may  cease 
and  pregnancy  may  go  on  to  full  term.  It  is  rare,  however, 
for  all  the  conditions  necessary  for  this  result  to  be  present. 
When  the  physician  is  summoned  to  such  a  case  and  finds 
the  uterus  not  very  tender,  the  pulse  and  temperature  but 
little  disturbed,  and  moderate  hemorrhage  only  with  the 
history  of  accident,  the  patient  should  be  put  at  absolute 
rest  in  bed,  sedative  medicines  should  be  given,  and  the 
patient  kept  under  close  observation,  with  the  hope  that 
pregnancy  may  continue. 

In  a  striking  case  in  the  experience  of  the  writer  a  patient 
pregnant  between  seven  and  eight  months  was  thrown  from 
a  sleigh,  following  which  bright  vaginal  hemorrhage  occurred. 
The  uterus  became  somewhat  tender,  and  the  pulse  and 
temperature  were  somewhat  elevated.  Rest  in  bed  with 
sedative  medicines  and  liquid  food,  resulted  in  cessation  of 
the  hemorrhage  and  the  continuance  of  pregnancy  to  full 
term,  with  the  spontaneous  birth  of  a  living  child. 

Where,  however,  the  symptoms  do  not  cease,  but  the 
uterus  becomes  more  tender  and  rigid,  and  the  pulse  and 
temperature  more  disturbed,  action  is  imperative. 

There  is  but  one  way  in  which  the  situation  can  be  con- 
trolled, and  that  is  by  emptying  the  uterus  in  the  most  prompt 
and  harmless  manner  possible.  Like  ectopic  gestation  these 
cases  should  be  at  once  taken  to  hospital.  If  the  pregnancy 
has  not  advanced  beyond  the  seventh  month,  many  opera- 
tors prefer  vaginal  Cesarean  section  under  antiseptic  pre- 
cautions and  under  careful  anesthesia.  If  pregnancy  is 


HEMORRHAGE    COMPLICATING    PREGNANCY  259 

further  than  the  seventh  month,  abdominal  Cesarean  section 
may  be  selected. 

If  the  patient  should  not  be  transported  to  hospital  and 
whatever  treatment  is  available  must  be  carried  out  in  a 
private  house,  the  use  of  the  tampon,  with  the  administra- 
tion of  opium,  has  given  good  results.  To  accomplish  this 
under  antiseptic  precautions,  the  urinary  bladder  is  emptied 
by  catheter  and  the  vagina  thoroughly  irrigated  with  1  per 
cent,  lysol.  The  vagina  is  then  packed  as  firmly  as  the  pa- 
tient can  endure  it  with  10  per  cent,  iodoform  gauze,  one 
strand  of  which  should  be  intrpduced  if  possible  through  the 
cervix.  A  firm  large  pad  is  then  placed  above  the  fundus  and 
a  large  many  tailed  bandage  applied  upon  th*e  abdomen  in 
such  a  manner  that  the  uterus  is  pressed  strongly  downward 
toward  the  pubes.  Sufficient  opium  is  given  by  hypoder- 
matic injection  to  relieve  the  patient's  pain  and  to  act  as  a 
cerebral  stimulant.  The  patient  should  be  kept  absolutely 
quiet,  but  under  close  observation.  After  a  varying  interval 
the  cervix  will  dilate  and  hemorrhage  may  occur  sufficiently 
to  stain  through  the  vaginal  packing.  Should  this  happen, 
this  packing  must  be  removed,  the  vagina  irrigated,  and  an- 
other packing  introduced  as  thoroughly  as  before.  Opium, 
strychnia  and  digitalin  may  be  administered  as  the  patient's 
condition  justifies,  until  the  uterus  begins  to  act  and  the 
cervix  is  at  least  one-half  or  more  dilated.  When  the  cervix 
becomes  dilated  or  dilatable  the  physician,  with  competent 
assistance,  may  remove  the  packing  cautiously,  complete 
dilatation  by  the  gloved  hand,  rupture  the  membranes,  and 
bring  down  a  foot  and  leg  of  the  fetus,  bringing  the  breech 
down  as  a  plug.  No  further  attempt  should  be  made  to  de- 
liver, but  the  uterus  should  be  stimulated  to  contraction  by 
strychnia,  ergot  or  pituitrin  hypodermatically  given.  When 
the  breech  is  expelled  spontaneously  the  physician  may  de- 
liver the  arms  and  head.  The  uterus  must  be  at  once  emp- 
tied of  the  placenta,  clots,  membranes  and  cord,  thoroughly 
irrigated  with  1  per  cent,  lysol,  and  packed  firmly  with  10 
per  cent,  iodoform  gauze.  The  patient  is  often  in  such  a 
condition  that  lacerations  cannot  be  immediately  repaired. 
Intravenous  saline  transfusion,  heat  beneath  the  cerebellum, 
the  Faradic  current,  the  inverted  position,  the  injection  of 


260  MANUAL   OF   OBSTETRICS 

adrenalin,  artificial  warmth,  fresh  air  and  oxygen,  and  opium 
as  a  cerebral  stimulant,  are  all  indicated. 

The  treatment  during  the  puerperal  condition  has  been 
described  under  the  treatment  of  placenta  praevia. 

The  mortality  from  accidental  separation  of  the  normally 
implanted  placenta  depends  upon  prompt  diagnosis  and 
efficient  treatment  under  antiseptic  precautions.  The  fre- 
quency of 'the  accident  can  only  approximately  be  estimated 
as  from  1  to  ^  per  cent,  in  a  large  number  of  cases.  The 
maternal  mortality  varies  from  32  to  46  per  cent.,  the  fetal 
mortality  from  85  to  94  per  cent.  The  morbidity  is  con- 
siderable because  hemorrhage  invites  infection,  and  manip- 
ulation is  necessary. 

Hemorrhage  Complicating  Pregnancy  from  Rupture  and 
Lacerations  of  Vessels. — The  veins  of  the  broad  ligaments 
become  enormously  distended  during  pregnancy  and  may 
rupture  from  direct  violence,  as  a  severe  fall,  a  blow,  or  a 
kick.  This  bleeding  can  only  be  inferred  from  the  general 
signs  and  symptoms  of  hemorrhage  with  tenderness  over  the 
broad  ligament.  Its  hidden  nature  and  uncertain  character 
demand  prompt  removal  to  hospital  and  treatment  by  ab- 
dominal section.  The  ruptured  veins  should  be  ligated  and 
intravenous  saline  transfusion  and  other  stimulation  em- 
ployed. 

Varicose  veins  in  the  vagina  or  vulva  or  in  the  lower  ex- 
tremities complicating  pregnancy  may  rupture  and  occasion 
severe  bleeding,  producing  syncope.  Fortunately  the  diag- 
nosis is  apparent  because  the  lesion  is  superficial.  Under 
antiseptic  precautions  the  ligation  of  the  veins  in  the  vulva 
and  vagina  and  in  the  lower  extremities,  and  the  applica- 
tion of  a  pad  over  the  point  of  rupture,  with  the  bandaging 
of  the  entire  extremity,  will  control  the  bleeding. 

Highly  toxemic  patients  may  bleed  during  pregnancy 
from  the  uterus  and  the  bleeding  may  be  uncontrollable  and 
prove  fatal.  The  altered  state  of  the  blood  is  responsible  for 
this  accident. 

Hemorrhage  from  Lacerations. — As  labor  proceeds,  the 
c(>rvix  may  lacerate  sufficiently  to  produce  hemorrhage. 
This  is  seen  in  cases  where  the  uterus  is  poorly  developed, 
where  the  tissues  are  inelastic,  and  the  cervix  does  not  dilate 


HEMORRHAGE    COMPLICATING    PREGNANCY  261 

normally.  Such  lacerations  are  usually  not  considerable  and 
such  cases  can  be  successfully  managed  by  making  multi- 
ple incisions  in  the  cervix,  rupturing  the  membranes,  and 
allowing  the  presenting  part  of  the  child  to  make  pressure 
upon  the  cervix.  It  is  often  necessary  to  terminate  labor  by 
artificial  extraction. 

During  labor,  when  the  head  is  upon  the  pelvic  floor,  the 
perineum  may  rupture  or  the  wall  of  the  vagina  may  tear  as 
the  head  descends.  Such  bleeding  is  usually  controlled  by 
the  pressure  of  the  presenting  part,  but  if  this  should  not  oc- 
cur sutures  should  be  taken,  the  needle  passing  deeply  be- 
neath the  point  of  hemorrhage. 

Internal  bleeding  during  labor  may  be  suspected  when 
without  known  cause  the  patient  suddenly  manifests  symp- 
toms of  shock  and  hemorrhage.  Usually  rupture  of  the 
uterus  accompanies  these  symptoms,  and  hemorrhage  is  an 
important  factor.  Immediate  removal  to  hospital,  and 
treatment  by  section  are  the  only  efficient  remedies. 

Hemorrhage  Occurring  after  Delivery  from  Lacerations. — 
The  torn  cervix  not  infrequently  bleeds  after  delivery  of  the 
child.  The  blood  is  bright  and  comes  constantly  in  a  small 
stream.  Torn  vessels  in  the  anterior  segment  of  the  pelvic 
floor  may  bleed  after  delivery,  and  from  them  the  hemorrhage 
is  bright,  inconsiderable  in  quantity,  but  constant.  Arteries 
in  the  posterior  segment  of  the  pelvic  floor  and  vagina  may 
also  sustain  laceration  and  bleed  after  labor. 

Diagnosis. — The  diagnosis  of  cervical  bleeding  is  impor- 
tant because  it  is  often  mistaken  for  bleeding  from  uterine 
sinuses  caused  by  relaxation  of  the  uterus  and  commonly 
known  as  post-part um  hemorrhage.  Bleeding  from  the 
cervix  may  occur  when  the  body  of  the  uterus  is  firmly  con- 
tracted. Bleeding  from  uterine  sinuses  is  copious,  often 
sudden,  and  sometimes  intermittent;  and  bleeding  from  the 
torn  cervix  is  comparatively  small  in  quantity,  bright  in 
color,  and  constant. 

Prophylactic  Treatment. — Where  it  is  evident  that  the 
cervix,  pelvic  floor  and  vagina,  will  dilate  with  difficulty  and 
that  laceration  is  inevitable,  this  may  be  lessened  by  the  use 
of  anesthesia  at  the  moment  of  delivery  and  by  preliminary 
dilatation  with  the  gloved  hand  of  the  physician.  If  artificial 


MANUAL    OF    OBSTETRICS 

delivery  be  practised  care  should  be  taken  to  extract  the  child 
slowly  and  with  intermittent  traction,  and  to  maintain  flex- 
ion of  the  head  during  delivery. 

Curative  Treatment. — The  treatment  of  lacerations  in  the 
cervix,  pelvic  floor  and  vagina,  accompanied  by  hemorrhage, 
consists  in  suture  under  antiseptic  precautions.  To  do  this 
a  favorable  position  of  the  patient,  a  good  light,  surgical 
appliances,  antiseptic  technic,  and  prompt  assistance,  are 
necessary.  Usually  anesthesia  can  be  avoided.  The  cervix 
should  be  grasped,  each  lip  separately  with  tenaculum  for- 
ceps, and  gently  drawn  down  until  it  can  be  readily  inspected. 
Lacerations  will  then  be  seen  and  usually  the  site  of  hem- 
orrhage. The  lacerations  should  be  closed  by  No.  2  chromi- 
cized  catgut.  If  the  uterus  has  been  packed  an  end  of  the 
gauze  should  be  brought  out  in  the  centre  of  the  cervical 
canal.  Care  must  be  exercised  to  carry  the  first  stitch  high 
up  at  the  side  of  the  cervix  so  that  it  may  compress  branches 
of  the  cervical  artery  which  are  large  at  that  point.  The 
proper  application  of  stitches  is  followed  by  the  immediate 
cessation  of  cervical  bleeding. 

Lacerations  of  the  anterior  segment  of  the  pelvic  floor  often 
bleed  persistently  and  may  greatly  annoy  the  physician. 
Here  immediate  continuous  suture  with  fine  catgut  promptly 
checks  the  hemorrhage. 

In  the  posterior  segment  of  the  pelvic  floor  and  perineum 
catgut  sutures  in  the  vagina,  carried  deeply  through  the 
tissues,  will  stop  bleeding,  while  in  the  perineum  deep  stitches 
of  fine  catgut  through  the  muscles'  and  vagina,  and  super- 
ficial stitches  of  silkworm  gut  will  stop  the  hemorrhage. 

In  private  houses,  under  the  care  of  the  general  practi- 
tioner, accurate  suture  under  antiseptic  precautions,  is  usu- 
ally impossible.  A  good  light  is  often  wanting,  assistance  is 
lacking,  an  antiseptic  outfit  may  not  be  at  hand,  and  while  the 
taking  of  these  stitches  is  not  a  serious  operation,  its  success 
requires  some  experience  and  operative  skill.  Under  these  cir- 
cumstances the  practitioner  will  control  hemorrhage,  at 
least  to  some  extent,  and  less  promptly  by  tamponing  the 
uterus,  if  this  has  not  been  done,  with  10  per  cent,  iodoform 
gauze,  and  firmly  packing  the  vagina  with  bichloride  or  iodo- 
form gauze.  A  firm  pad  over  the  perineum  and  a  firm  gauze 


HEMORRHAGE    COMPLICATING    PREGNANCY  263 

compress  over  the  anterior  segment  of  the  pelvic  floor,  with 
a  strong  T-bandage,  will  make  efficient  pressure. 

Post-Partum  Hemorrhage.— By  this  term  is  commonly 
meant  hemorrhage  from  the  genital  tract  following  labor. 
But  much  of  this  is  hemorrhage  from  lacerations  in  the 
cervix,  the  pelvic  floor  and  perineum. 

The  treatment  of  these  lacerations,  and  the  treatment  of 
post-partum  hemorrhage  from  relaxation  of  the  uterus  and 
the  patent  condition  of  the  uterine  sinuses,  is  so  different 
that  the  term  post-partum  hemorrhage  is  often  inaccurate 
and  misleading.  We  understand  by  post-partum  hemorrhage 
bleeding  from  the  uterine  sinuses  caused  by  relaxation  of 
the  uterine  muscle. 

Etiology. — Those  cases  which  predispose  to  a  relaxed  and 
weak  condition  of  the  muscular  system  of  the  patient,  and 
especially  of  the  uterus,  predispose  to  post-partum  hemor- 
rhage. Such  are  rapidly  repeated  pregnancies,  over-dis- 
tention  of  the  uterus  from  an  excessively  large  child  or  twins, 
or  polyhydramnios,  an  acute  infection  like  pneumonia  or  ty- 
phoid fever,  which  affects  not  only  the  blood  but  the  muscle 
of  the  uterus,  poor  development  of  the  uterine  muscle,  as  in 
anemic  primiparse,  and  the  exhaustion  and  muscular  disten- 
tion  incident  to  prolonged  and  difficult  labor.  Toxemia 
from  any  cause  greatly  predisposes  to  hemorrhage  because  it 
reduces  the  coagulating  power  of  the  blood,  alters  the  sub- 
stance of  the  muscle,  and  thus  prevents  competent  contrac- 
tion. Rapid  delivery  by  forceps  or  version  when  the  uterus 
is  not  acting  may  be  followed  by  complete  relaxation  and 
severe  bleeding. 

Signs  and  Symptoms. — The  signs  and  symptoms  of  hem- 
orrhage from  a  relaxed  uterus  are  the  appearance  of  a  copi- 
ous flow  of  blood  from  the  vagina.  If,  however,  the  blood 
clots  firmly  in  the  uterus  the  clot  may  close  the  cervix  and 
blood  accumulate  within  the  uterus,  and  external  hemorrhage 
be  very  slight.  Under  these  circumstances,  the  intrauterine 
clot  slowly  increases  in  size  until  it  excites  strong  uterine 
contractions,  when  the  clot  may  be  expelled  followed  by  free 
bleeding,  exhaustion  and  shock.  Patients  may  bleed  se- 
verely from  a  relaxed  uterus  and  still  recover,  if  they  do  not 


264  MANUAL   OF   OBSTETRICS 

become  infected.  In  some  patients  twenty-four  hours  after 
the  initial  hemorrhage,  relaxation  and  bleeding  recur. 

Prophylaxis. — No  case  of  labor  should  receive  attention 
by  physicians  without  prophylactic  treatment  for  post- 
partum  hemorrhage.  This  consists  in  bringing  the  woman 
to  labor  in  the  best  possible  condition.  Relaxation  of  the 
uterine  muscle  is  preceded  by  exhaustion,  and  the  signs  and 
symptoms  of  this  condition  should  be  accurately  known  by 
the  physician,  and  instruction  in  this  knowledge  should  also 
be  given  to  trained  nurses. 

Gradual  failure  in  the  vigor,  force  and  frequency  of  uterine 
contractions,  increasing  rapidity  of  the  patient's  pulse,  with 
a  weaker  pulse,  slight  disturbance  of  temperature,  restless- 
ness, failure  to  sleep,  and  beginning  distention  of  the  ab- 
domen with  gas,  are  signs  of  exhaustion  which  should  not 
be  overlooked.  These  patients  sometimes  become  excitable, 
suffering  severely  mentally,  and  begging  for  relief.  At 
other  times  they  are  apathetic  and  often  stuporous. 

Diagnosis. — The  diagnosis  of  exhaustion  of  the  uterine 
muscle  in  labor  cannot  be  made  without  a  thorough  knowl- 
edge of  obstetrics.  First  in  importance  is  the  ascertaining 
of  the  presence  of  some  mechanical  condition  which  is  making 
spontaneous  labor  impossible.  Such,  for  example,  would 
be  contracted  pelvis,  overgrown  child,  posterior  rotation  of 
the  occiput  or  the  chin,  brow  presentation,  parietal  bone  pres- 
entation, transverse  position  in  shoulder  presentation,  cord 
coiled  about  the  fetus  shortening  the  free  portion,  a  greatly 
distended  urinary  bladder,  excessive  cold  in  the  external  at- 
mosphere, and  the  debilitating  effect  of  excessive  heat. 

When  exhaustion  has  reached  the  stage  of  tetanic  con- 
traction of  the  uterine  muscle,  which  precedes  relaxation,  the 
uterus  is  firm,  tender  upon  palpation,  and  the  patient's  pulse 
and  temperature  are  considerably  elevated.  Accompany- 
ing the  muscular  exhaustion  is  the  general  fatigue  of  the 
nervous  system,  which  shows  itself  in  restlessness,  inability 
to  sleep,  constant  complaint  of  pain,  and  sometimes  in 
nausea  and  vomiting.  The  pulse  becomes  rapid  and  often 
weak,  and  the  patient's  expression  anxious  and  haggard. 

The  Diagnosis  of  Hemorrhage. — Ordinarily  hemorrhage 
is  evident  because  blood  from  the  uterus  escapes  through 


HK.MORRHAGE    COMPLICATING    PREGNANCY 


265 


the  vagina.  If,  however,  a  clot  forms,  closing  the  cervix, 
the  blood  may  be  retained  and  the  uterus  gradually  become 
distended,  while  bleeding  continues.  The  condition  of  the 
uterine  muscle  is  the  most  valuable  sign  in  recognizing  the 
severity  of  hemorrhage.  If  the  uterus  be  small  and  firm, 
continuous  hemorrhage  comes  from  a  torn  cervix;  if  hem- 
orrhage be  profuse  and  the  uterus  be  flabby  so  that  it  can 
scarcely  be  outlined,  blood  is  pouring  from  the  uterine  si- 
nuses. If  there  be  moderate  vaginal  hemorrhage,  but  the 
uterus  is  soft  on  pressure  and  steadily  enlarging,  a  clot  is  re- 


Fig.  108. — Grasping  the  uterus  after  delivery  to  prevent  post-partum 

hemorrhage. 

tained  within  the  uterine  cavity.  Where  uterine  rupture 
occurs  with  intra-abdominal  hemorrhage  and  sudden  pain 
and  shock,  followed  by  cessation  of  uterine  contractions,  it 
indicates  rupture. 

The  Results  of  Post-Partum  Hemorrhage. — If  post-partum 
hemorrhage  be  not  controlled,  the  patient  may  bleed  to  syn- 
cope, and  death  may  ensue  from  the  formation  of  pulmonary 
embolism  or  acute  cerebral  anemia.  If  the  patient  does  not 
perish  immediately,  septic  infection  is  very  apt  to  supervene 
and  prove  fatal.  If  the  patient  survives  hemorrhage  and 


266 


MANUAL   OF   OBSTETRICS 


sepsis,  thrombosis  is  likely  to  develop,  convalescence  is 
rarely  retarded,  and  the  patient  may  be  unable  to  nurse  her 
child. 

Treatment. — It  is  useless  to  treat  post-partum  hemorrhage 
without  having  first  in  importance  the  condition  of  the  uter- 
ine muscle.  When  hemorrhage  occurs,  the  uterus  should  at 
once  be  firmly  grasped  between  the  four  fingers,  carried  di- 
rectly down  and  behind  the  uterus,  and  a  thumb  placed  upon 

the  centre  of  the  ante- 
rior uterine  wall.  If  the 
uterus  is  not  grasped 
parallel  to  its  long  axis, 
but  if  the  hand  is  ap- 
plied to  the  side  of  the 
uterus,  the  ovary  may 
be  pinched  by  pressure, 
and  the  patient  may 
manifest  signs  of  pain 
and  shock.  The  uterus 
properly  grasped  should 
be  compressed  firmly 
and  carried  forward 
over  the  pubes.  If  the 
womb  is  so  relaxed  that 
it  cannot  be  grasped, 
it  must  be  briskly  but 
lightly  rubbed  and 
kneaded  until  its  shape 
is  distinctly  outlined 
and  it  can  be  grasped. 
So  soon  as  this  has 
been  effected  the  pa- 
tient should  be  given 
strychnia  -fa  to  ^5-  grain,  digitalin  fa  grain,  atropin  ^-j^- 
grain,  together  hypodermatically.  A  preparation  of  ergot 
suitable  for  hypodermatic  use  should  be  given,  a  syringeful 
injected  at  a  time  deeply  into  the  muscles  of  the  thigh  or  in 
the  buttocks.  This  dose  of  ergot  should  be  repeated  in  half 
an  hour  if  needed.  A  copious  hot  vaginal  irrigation  of  boiled 
water,  sterile  salt  solution,  or  lysol  1  per  cent.,  should  be  given 


Fig.  109. — The  correct  and  success- 
ful tamponing  of  the  genital  tract  in 
post-partum  bleeding. 


HEMORRHAGE    COMPLICATING    PREGNANCY 


267 


with  a  long  suitably  curved  glass  tube,  and  the  tube  should 
be  inserted  within  the  cervix  to  wash  out  any  clot  that  may 
be  in  the  lower  uterine  segment. 

These  measures  will  control  nine  out  of  ten  cases  of  post- 
partum  hemorrhage.  Should  the  uterus  after  responding 
to  treatment  again  relax,  it  will  be  necessary  to  irrigate  the 
uterine  cavity  with  hot  1  per  cent,  lysol,  or  sterile  salt  solu- 
tion, and  to  pack  it  thoroughly  with  10  per  cent,  iodoform 


Fig.  110. — The  genital  tract  inefficiently  tamponed  to  prevent 
post-partum  hemorrhage;  a,  a  clot  which  formed  [in  the  empty  fundus 
above  the  gauze;  b,  the  gauze  not  carried  beyond  the  lower  portion  of 
the  uterine  cavity  (after  Bumm). 

gauze.  This  procedure  is  dangerous  unless  the  physician 
has  the  necessary  appliances  to  maintain  asepsis.  Several 
assistants,  physicians  or  nurses,  are  needed  to  control  the 
patient  during  this  application.  Anesthesia  should  be 
avoided  if  possible. 

To  insert  the  packing  without  anesthesia  the  vagina 
should  be,  irrigated  with  1  per  cent,  lysol,  and  the  gloved 
left  hand  introduced  within  the  vagina  with  the  fingers  be- 


268  MANUAL    OF   OBSTETRICS 

hind  the  cervix,  the  palm  being  directed  toward  the  pubes. 
The  end  of  the  strip  of  gauze  in  uterine  dressing  forceps  is 
then  passed  along  the  palm  of  the  hand  within  the  vagina  to 
the  cervix  and  introduced  within  the  cervix.  Several  folds 
of  gauze  are  thus  carried  into  the  cervix,  when  the  fingers  of 
the  left  hand  should  be  inserted,  and  with  the  fingers  the 
gauze  should  be  thoroughly  packed  at  the  fundus  of  the 
uterus.  During  this  manipulation  the  uterus  should  be  pressed 
downward  by  an  assistant,  and  the  gauze  should  be  intro- 
duced by  the  forceps  and  fingers  until  the  entire  cavity  of  t he 
uterus  is  thoroughly  tamponed.  Sufficient  gauze  should 
be  left,  to  which  can  be  tied  a  strip  of  bichloride  gauze  with 
which  the  vagina  should  be  firmly  packed. 


Fig.   111. —  Momburg's  tourniquet  bandage  applied  to  check  uterine 
hemorrhage  (Leipmann). 

It  is  dangerous,  unless  the  uterus  is  grasped  by  tenacu- 
lum  forceps,  and  drawn  down,  to  tampon  the  uterus  with 
dressing  forceps  alone,  as  this  instrument  may  be  passed 
through  the  uterine  wall.  If  the  forceps  be  used  to  place 
the  gauze  only  within  the  cervix,  and  the  gauze  be  packed 
by  the  hand,  the  operator  can  be  sure  that  the  fundus  is 
properly  tamponed  and  that  the  packing  is  efficient.  If 
the  packing  does  not  reach  the  fundus,  bleeding  will  continue 
above  the  gauze  and  a  clot  form,  which  will  prevent  proper 
contraction  of  the  womb. 

Patients  sometimes  complain  of  considerable  pain  from 
uterine  contractions,  increased  by  the  presence  of  gauze. 
If  such  pain  is  severe  and  annoying,  a  moderate  dose  of 


HEMORRHAGE    COMPLICATING    PREGNANCY  269 

morphia  should  be  given  hypodermatically.  Salt  solution 
should  be  introduced  by  hypodermoclysis  or  by  rectal 
injection,  combined  with  whiskey  and  freshly  made  hot 
coffee.  In  extreme  cases  intravenous  saline  transfusion 
should  be  practised.  Adrenalin  1  to  1000  may  be  added  to 
the  salt  solution  if  desired.  When  the  uterus  remains  con- 
tracted for  some  time,  the  grasp  of  the  hand  may  be  omitted 
and  a  firm  pad  placed  above  the  fundus,  and  a  many  tailed 
bandage  applied  over  the  abdomen,  carrying  the  uterus 
downward  and  forward.  The  foot  of  the  bed  should  be 
elevated  so  that  the  patient  is  in  the  Trendelenberg  posture, 
the  lower  limbs  may  be  bandaged  from  the  feet  to  the  groin, 
and  the  upper  limbs  from  the  fingers  to  the  axilla;  a  hot 
water  bottle  covered  with  dry  flannel  should  be  placed  be- 
neath the  cerebellum,  oxygen  should  be  inhaled,  and  the 
patient's  body  surrounded  by  external  warmth.  The  Fara- 
dic  current,  one  pole  beneath  the  cerebellum  and  one  over 
the  uterus;  or  one  pole  beneath  the  cerebellum  and  the  other 
over  the  heart,  is  an  excellent  stimulant.  Pituitrin  is  valu- 
able to  secure  rapid  and  vigorous  uterine  contraction,  but 
its  effect  is  less  enduring  than  that  of  ergot  and  strychnia. 

Secondary  Hemorrhage. — Usually  within  twelve  hours 
a  secondary  collapse  with  relaxation  and  hemorrhage  must 
be  expected.  To  prevent  this,  strychnia,  digitalin  and  ergot 
should  be  given  hypodermatically  at  intervals  of  three  or 
four  hours.  After  the  first  dose  of  morphia,  codein  in  ^ 
gram  doses,  should  be  substituted.  Rectal  injections  of 
whiskey  and  salt  solution  should  be  given  every  four  hours. 
Warmth  should  be  continuously  applied,  oxygen  inhaled, 
and  by  the  mouth  small  quantities  of  hot  water  with  aro- 
matic spirits  of  ammonia.  With  these  precautions,  the 
development  of  secondary  shock  can  often  be  prevented  and 
the  patient  gradually  brought  into  a  tranquil  condition, 
when  she  will  sleep. 

If  she  is  desirous  of  seeing  the  child,  and  the  child  be  in 
good  condition,  it  may  be  put  to  the  breast  once  or  twice. 

So  soon  as  the  danger  of  secondary  shock  is  over,  the 
patient  should  be  given  peptonized  milk,  orange  albumin, 
broth,  beef  juice,  or  raw  eggs  beaten  up,  every  two  hours. 
If  she  craves  tea  or  coffee,  such  may  be  used  sparingly. 


270  MANUAL   OF   OBSTETRICS 

Care  must  be  taken  to  avoid  disturbing  the  stomach,  and 
formation  of  gas,  and  only  very  easily  digested  food  hi  small 
quantities  should  be  given  frequently. 

The  pad  above  the  uterus  should  be  retained  and  the 
gauze  packing,  for  from  forty-eight  to  seventy-two  hours. 
When  the  gauze  is  removed  the  uterus  should  be  thoroughly 
irrigated  with  warm  lysol,  and  no  further  irrigation  should 
be  practised.  After  the  first  week  of  convalescence,  the 
patient  should  receive,  in  place  of  strychnia  and  ergot,  nux 
vomica,  Fowler's  solution  and  gentian,  before  food,  and  a 
suitable  preparation  of  iron  after  food,  four  times  daily. 

Uncontrollable  Hemorrhage. — Cases  are  occasionally  seen 
where  post-partum  hemorrhage  is  uncontrollable.  A  highly 
toxemic  condition  of  the  mother  may  render  this  possible, 
the  patient  may  apparently  recover  from  post-partum 
bleeding,  but  the  uterus  remains  large,  and  frequent  attacks 
of  irregular  hemorrhage  may  develop.  In  these  cases,  one 
must  suspect  the  formation  of  syncytioma  malignum.  In 
some  patients  a  pendunculated  fibroid,  which  has  become  a 
fibroid  polyp  during  labor,  may  be  retained  within  the 
uterus  and  cause  repeated  and  considerable  bleeding.  Occa- 
sionally a  small  portion  of  retained  placenta  may  cause 
severe  and  irregular  hemorrhage,  which  does  not  cease  until 
the  portion  of  placenta  has  been  removed. 

The  Treatment  of  Complications. — Where  secondary 
hemorrhage  with  shock  develops,  it  is  usually  necessary  to 
remove  the  gauze  packing  and  to  re-apply  it.  In  the 
hemorrhage  of  toxemia  packing  should  be  used,  although  if 
the  toxemia  be  severe  treatment  is  unavailing,  and  the 
patient  dies.  Where  repeated  hemorrhage  depends  upon 
the  presence  of  a  polyp,  it  will  cease  upon  the  removal  of  the 
polyp;  and  where  syncytioma  malignum  is  present,  extirpa- 
tion of  the  uterus  is  the  only  procedure  which  will  control 
the  bleeding. 

The  Instruction  of  Nurses  in  Managing  Post-Partum 
Hemorrhage. — In  all  efficient  training  schools  for  nurses 
and  in  maternity  hospitals  nurses  are  instructed  to  control 
post-partum  hemorrhage  until  a  physician  can  arrive.  The 
signs  and  symptoms  of  exhaustion  are  clearly  described,  and 
those  methods  of  treatment  which  the  nurse  can  carry  out 


HEMORRHAGE    COMPLICATING    PREGNANCY  271 

are  plainly  taught.  We  are  accustomed,  in  the  Maternity 
Department  of  the  Jefferson  Hospital,  to  instruct  nurses 
when  relaxation  and  hemorrhage  occur,  to  do  three  things, 
hi  the  order  named : 

First,  to  remove  any  binder  or  bandage  from  the  abdomen, 
to  rub  the  uterus  until  it  can  be  grasped,  to  grasp  it  firmly, 
and  to  carry  it  forward  and  downward  over  the  pubes  and 
hold  it  there. 

Second,  to  give  to  the  patient  hypodermatically  -^  grain 
of  strychnia,  -V  grain  of  digitalin,  and  one  syringeful  of  a 
suitable  preparation  of  ergot  for  hypodermatic  use.  Pitui- 
trin  may  be  substituted  for  ergot. 

Third,  to  give  to  the  patient  a  copious  hot  vaginal  douche 
of  1  per  cent,  lysol,  salt  solution,  or  boiled  water,  the  glass 
tube  to  be  carried  Into  the  cervix  and  into  the  external  os. 

This  instruction  has  enabled  our  nurses  to  control  all  cases 
of  post-part  um  hemorrhage  occurring  in  the  absence  of  a 
physician  until  a  doctor  arrives. 

Lactation  After  Hemorrhage. — Lactation  is  often  slow  in 
developing  and  the  child  may  not  at  first  thrive  upon  the 
milk  of  a  mother  who  has  suffered  from  hemorrhage.  The 
effort  to  have  the  mother  nurse  the  child  must  not  be  aban- 
doned, and  the  child  should  be  artificially  fed  until  the 
mother  recovers  from  the  first  anemia  and  shock.  To 
encourage  secretion  of  milk,  if  the  child  does  not  nurse,  the 
breasts  should  be  pumped  several  times  daily  and  gently 
massaged. 

Death  From  Exhaustion  Following  Hemorrhage. — In  some 
cases,  although  bleeding  ceases,  it  seems  impossible  for  the 
patient  to  rally.  Stimulation  may  be  pushed  as  far  as  is 
permissible,  but  the  patient  remains  in  a  wakeful,  somewhat 
restless  condition,  with  very  rapid  and  feeble  pulse  and  sub- 
normal temperature.  In  these  cases,  if  the  patient  be  put 
at  absolute  rest  and  given  morphia  hypodermatically,  the 
nervous  system  may  rally  and  the  patient  recover.  Strych- 
nia must  be  used  with  caution  in  these  cases,  for  if  given  in 
excess  it  tends  to  exhaust  rather  than  stimulate  the  patient. 


272  MANUAL  OF   OBSTETRICS 


SEPTIC  INFECTION 

By  septic  infection  we  understand  the  entrance  into  the 
mother's  lymphatic  and  blood  circulation,  before,  during  or 
after  labor,  of  pathogenic  bacteria.  The  organism  resists 
such  infection  by  fever  and  so  the  term  septic  fever  is  often 
applied.  As  such  most  frequently  develops  after  labor,  the 
term  puerperal  fever  has  been  long  in  use. 

The  Causes  of  Septic  Infection. — The  streptococcus  is  the 
most  common  and  efficient  cause  of  septic  infection  in  par- 
turient women.  Staphylococci,  the  pneumococcus,  the 
bacillus  coli  communis,  the  bacillus  proteus  vulgaris,  the 
diphtheria  bacillus,  the  germ  of  erysipelas,  and  various 
diplococci,  may  cause  this  condition.  In  some  cases  un- 
classified bacteria  are  present. 

The  Mode  of  Infection. — Infection  may  arise  among  par- 
turient women  from  germs  already  in  the  body  before  preg- 
nancy or  labor,  or  from  germs  introduced  usually  within  the 
birth  canal  by  some  manipulation. 

While  researches  are  confusing  concerning  the  bacteriology 
of  the  vagina,  it  is  admitted  by  most  that  streptococci  and 
other  bacteria  are  often  present  in  the  vagina  in  pregnant 
women  who  are  apparently  in  good  health.  While  their 
growth  is  usually  inhibited  by  the  acid  mucous  secretion  of 
the  vaginal  mucous  membrane,  and  while  the  entrance  of 
these  bacteria  into  the  uterine  cavity  is  generally  prevented 
by  a  plug  of  tenacious  sterile  mucus  in  the  cervix,  still  bac- 
teria from  the  vagina  frequently  gain  access  to  the  uterine 
cavity  and  may  enter  the  circulation  at  the  placental  site. 

Septic  infection  by  direct  contamination  is  seen  in  its  most 
complete  example  in  the  work  of  the  criminal  abortionist. 
In  his  hand  a  non-sterile  uterine  sound  is  introduced  through 
the  cervix  during  early  pregnancy,  carried  roughly  about 
the  uterine  cavity  until  it  ruptures  the  sac  of  the  embryo  and 
wounds  the  decidua,  and  often  the  wall  of  the  uterus.  In 
other  cases  of  criminal  abortion  the  patient  herself  may 
introduce  an  object  which  is  not  sterile  within  the  uterus, 
or  dirty  midwives  or  other  attendants,  by  repeated  vaginal 
examination,  may  wound  the  mucous  membrane  in  the  cervix 
and  introduce  bacteria  into  its  lacerations. 


SEPTIC    INFECTION  273 

The  Course  of  Septic  Infection. — The  course  of  septic  in- 
fection in  parturient  patients  will  depend  upon  the  virulence 
of  the  infective  germ,  and  the  mode  and  location  of  its  intro- 
duction within  the  patient's  body.  If  streptococci  in  pure 
culture  are  introduced  into  the  blood  stream  at  the  placental 
site  or  through  some  lacerated  surface,  severe  constitu- 
tional infection  will  rapidly  develop.  If  less  virulent  bac- 
teria, in  mixed  cultures,  be  introduced  into  a  wound  or 
laceration  of  the  mucous  membrane  of  the  genital  tract, 
lymphangitis  will  result  and  the  infection  will  develop  much 
more  gradually.  If  the  patient  has  been  a  subject  of  previous 
salpingitis  and  has  pyosalpinx  when  conception  occurs, 
should  this  pyosalpinx  rupture  during  pregnancy,  or  during 
or  after  labor,  its  contents  may  be  highly  virulent  and  rap- 
idly developing  peritonitis  may  result. 

Where  cancer  of  the  cervix  complicates  pregnancy  and 
labor  mixed  infection  almost  inevitably  develops.  Staphy- 
lococci,  probably  from  the  skin,  gain  access  to  the  mammary 
glands  during  pregnancy  and  have  been  extracted  from  the 
first  breast  milk  before  the  child  has  tried  to  nurse.  Any 
pre-existing  focus  of  infection  containing  pus  or  cultures  of 
bacteria  which  may  have  ruptured  during  or  after  labor  may 
result  in  active  infection. 

Pathology. — The  pathology  of  septic  infection  in  partu- 
rient women  is  essentially  that  of  wound  infection  in  sur- 
gical cases.  Where  streptococci  enter  the  blood  directly, 
if  the  patient's  immunizing  powers  are  not  sufficiently  great 
to  destroy  the  bacteria  they  rapidly  establish  metastatic  foci 
in  the  lungs,  liver,  spleen,  kidneys  and  brain,  and  in  various 
portions  of  the  peritoneum,  the  walls  of  the  uterus  and  con- 
nective tissue  and  vessels  of  the  broad  ligaments  and  pelvis, 
and  may  produce  multiple  embolism  and  thrombosis.  The 
toxins  formed  by  these  bacteria  exert  a  poisonous  and 
paralyzing  influence  upon  the  heart  muscle,  death  occurring 
from  cardiac  syncope. 

Where  staphylococci  and  their  bacteria  in  mixed  culture 
be  present  lymphangitis  usually  develops,  with  foci  of  infec- 
tion and  abscess  formation  in  the  course  of  the  lymphatics. 
Pyemia  may  ultimately  result  with  joint  infection,  and 
pyemic  involvement  of  serous  membranes  such  as  the  peri- 
18 


274  MANUAL   OF   OBSTETRICS 

cardium  and  pleurae  and  peritoneum.  As  the  uterus  is 
usually  the  organ  through  which  infection  enters  the  cir- 
culation, and  the  general  organism,  it  exhibits  all  the  char- 
acteristic lesions  of  sepsis.  The  lymphatics  early  become 
infected  and  the  uterine  decidua.  Infected  bacteria  break 
through  the  zone  of  cellular  resistance  beneath  the  decidua 
and  enter  the  lymphatics  and  blood  vessels  between  the 
muscle  fibres.  The  uterine  peritoneum  becomes  involved, 
infection  spreads  to  the  Fallopian  tubes,  and  pelvic  peri- 
toneum and  pelvic  abscess  may  form.  Small  suppurative 
foci  may  also  develop  in  various  organs  of  the  body  and  sup- 
purative meningitis,  pleurisy  or  peritonitis,  may  occur.  In 
mixed  infection  when  patients  perish  it  is  usually  from  ex- 
haustion and  pyemia. 

Septic  Infection  During  Pregnancy. — In  those  cases  where 
the  original  point  of  infection  can  be  made  out,  lymphangitis 
can  usually  be  traced  from  this  point  through  the  generative 
tract.  In  the  early  months  septic  infection  is  usually  pre- 
ceded by  abortion.  In  later  oregnancy,  when  the  mem- 
branes have  formed,  septic  infection  may  develop  in  the 
uterine  decidua  through  contamination,  and  infective  bacteria 
may  make  their  way  through  the  membranes  and  attack  the 
fetus.  Thus  the  fetus  in  utero  delivered  by  Cesarean  section 
has  developed  gonorrheal  ophthalmia. 

Septic  Infection  During  Labor. — If  the  pregnant  patient 
has  a  focus  of  previous  infection  with  retained  septic  material, 
the  disturbance  of  labor  may  rupture  the  collection  and  cause 
septic  material  to  enter  the  lymphatics  and  blood  vessels. 
If  the  patient  has  been  infected  by  contamination  early  in 
labor,  and  birth  be  prolonged,  acute  lymphangitis  may  re- 
sult. Repeated  vaginal  manipulation  and  examination 
without  proper  antiseptic  precautions  may  cause  fresh  in- 
fection, and  in  prolonged  labor  may  result  in  conditions  of 
great  gravity. 

Treatment. — The  treatment  of  septic  infection  compli- 
cating pregnancy  calls  for  the  emptying  of  the  uterus  in  that 
manner  which  shall  be  attended  by  the  least  traumatism. 
Dilatation  of  the  cervix  with  solid  dilators  sufficient  to  per- 
mit packing  of  the  uterus  with  a  narrow  strip  of  gauze  will 
be  sufficient.  Under  stimulation  with  strychnia,  the  uterus 


PUERPERAL   SEPTIC    INFECTION  275 

will  expel  its  contents  including  infected  material.  If  septic 
metritis  be  present  in  the  early  months,  the  uterus  may  be 
removed  through  the  vagina  and  the  pelvic  cavity  be  drained. 
If  there  is  reason  to  believe  that  the  uterus  has  been  rup- 
tured by  the  sound  of  the  criminal  abortionist,  abdominal 
section,  hysterectomy,  and  drainage  may  be  performed. 

Septic  infection  developing  during  labor  calls  for  the  ter- 
mination of  pregnancy  in  that  manner  which  shall  occasion 
the  least  traumatism  to  the  birth  canal.  The  use  of  dilating 
bags,  if  the  child  be  small,  or  craniotomy  upon  the  full  term 
child,  may  be  advisable.  At  or  near  term  the  Porro  operation 
with  extra-peritoneal  treatment  of  the  stump,  may  save  the 
mother's  life. 

PUERPERAL  SEPTIC  INFECTION 

This  condition  most  commonly  results  from  a  deposit  of 
pathogenic  bacteria  in  wounds  and  abrasions  in  the  peri- 
neum, pelvic  floor  and  cervix.  From  forty-eight  to  sev- 
enty-two hours  after  such  invasion  the  patient  has  a  rise  of 
temperature  and  pulse,  sometimes  preceded  by  a  chill.  The 
height  of  the  fever  will  depend  upon  the  virulence  of  the 
infective  agent  and  the  resisting  power  of  the  patient.  If 
thrombosis  and  embolism  be  not  present,  the  increase  in  the 
pulse  will  correspond  with  the  rise  in  temperature;  but  if 
thrombosis  and  embolism  in  any  degree  be  present  the  pulse 
will  be  more  disturbed  than  the  temperature.  Locally  the 
patient  will  complain  of  burning  and  pain  in  the  genital 
organs,  especially  upon  any  disturbance  and  manipulation. 
A  film  or  secretion  of  yellow-grayish  pus  forms  upon  abraded 
and  infected  surfaces,  which  consists  largely  of  leukocytes  and 
bacteria.  The  initial  rise  of  temperature  and  the  pulse  dis- 
turbance are  followed  by  remission  and  the  temperature  may 
fall  several  degrees.  During  the  following  afternoon  or 
evening  the  temperature  and  pulse  again  rise,  and  remain 
comparatively  high  during  the  night.  If  infective  bacteria 
make  their  way  along  the  lymphatics  the  cervix  is  entered 
and  also  the  lymphatics,  the  uterus  and  the  decidua.  The 
lochial  discharge  is  at  first  suppressed  and  then  becomes 
altered  in  character.  If  streptococci  predominate  the  lochial 
discharge  is  dark  red  with  little  if  any  odor,  and  clots  but 


276  MANUAL   OF   OBSTETRICS 

feebly.  If  mixed  infection  predominates  the  lochial  dis- 
charge is  muco-purulent,  with  characteristic  odor.  The 
secretion  of  milk  is  checked  and  the  uterus  becomes  involved, 
and  the  patient  complains  of  pain  in  the  abdomen.  The 
abdominal  wall  is  sensitive  to  palpation  and  the  abdominal 
muscles  are  partly  fixed  to  prevent  pain.  If  the  uterus  be 
palpated  it  is  tender  on  pressure. 

As  the  infection  travels  upward  from  the  uterus,  the 
veins  of  the  broad  ligaments  become  thrombosed  and  chills, 
followed  by  fever  and  sweating,  will  give  evidence  of  pyemia. 
Other  septic  foci  from  various  portions  of  the  body  may  de- 
velop, and  septic  pleurisy  with  exudate  or  pericarditis  or 
endocarditis,  or  peritonitis,  may  result.  Where  emboli 
form  the  joints  become  involved  and  multiple  joint  abscess 
may  develop.  The  meninges  of  the  brain  and  cord  may  be 
attacked  and  meningitis  with  exudate  or  cerebral  abscess  may 
result,  in  virulent  streptococcus  infection  the  embolic 
phenomena  may  predominate  and  retinal  embolism  may 
cause  blindness.  The  action  of  the  bowels  is  usually  checked 
at  first  and  gas  accumulates  in  the  intestine,  but  this  is  often 
succeeded  by  diarrhea  and  sometimes  by  septic  enteritis. 
The  urine  is  albuminous  and  may  contain  bacteria  in  abun- 
dance. Cystitis  is  not  uncommon  and  surgical  kidney  may 
develop.  Death  usually  results  from  exhaustion,  from 
cloudy  swelling,  and  fatty  degeneration  of  the  heart  muscle 
with  acute  dilatation.  Death  from  exhaustion  more  than 
from  any  one  lesion  is  not  uncommon. 

The  duration  of  mixed  infection  in  the  puerperal  period 
may  vary  greatly  in  proportion  to  the  virulence  of  the  bac- 
teria and  the  patient's  power  of  resistance.  Where  strep- 
tococci predominate,  a  fatal  termination  may  result  in  a 
week  or  ten  days  after  the  initial  lesion.  Where  lymphan- 
gitis with  mixed  infection  is  present  and  metastasis  de- 
velops the  patient  may  be  ill  for  weeks  or  even  several 
months,  finally  perishing  from  exhaustion. 

Direct  infection  of  the  blood  stream  at  the  placental  site, 
with  streptococci,  is  the  most  virulent  and  active  form  of 
puerperal  sepsis.  These  cases  often  result  from  the  manual 
removal  of  the  placenta  without  antiseptic  precautions.  In 
these  cases  there  are  no  infected  lesions  in  the  lower  genital 


PIERPERAL   SEPTIC    INFECTION  277 

trad,  the  lochia  remains  a  dark  reddish  fluid  with  little  or  no 
odor,  peritonitis  may  be  present  in  extreme  degree  or  absent, 
and  death  visually  ensues  from  multiple  embolism.  Multiple 
skin  lesions  in  petechial  patches  may  be  present. 

In  all  septic  infections  the  uterus  remains  in  subinvolu- 
tion,  is  larger  than  normal,  and  the  uterine  muscles  softened 
and  infiltrated  with  bacteria  and  their  products. 

In  puerperal  septic  infection  the  mammary  glands  may 
become  involved  and  septic  metastasis  may  develop.  The 
milk  is  unfit  for  the  child's  use,  as  it  contains  bacteria  and 
toxins.  The  child  may  become  infected  with  the  mother 
and  manifest  the  characteristic  signs  and  symptoms  of  the 
condition. 

The  Resistance  of  the  Organism  to  Infection. — The  re- 
sistance of  the  organism  to  infection  is  shown  by  fever,  by 
the  development  of  leukocytosis,  by  fixation  abscess,  by 
eliminating  discharge  as  diarrhea  and  sweating,  and  by  the 
patient's  inability  in  many  cases  to  take  large  quantities  of 
nourishment  of  those  substances  which  increase  the  resist- 
ing power  of  the  blood.  It  is  noticeably  true  in  iron  and 
arsenic,  which  may  often  be  pushed  to  extraordinary  quan- 
tities in  these  patients.  The  patient's  thirst  shows  the  neces- 
sity for  a  free  supply  of  water  to  maintain  the  circulation. 
The  immunizing  subtances  in  the  patient's  blood,  the  anti- 
toxins and  antigens  which  are  formed  in  favorable  cases, 
greatly  disturb  the  bacteria  and  neutralize  their  antitoxins. 
The  patient  may  be  said  to  be  making  a  good  fight  against 
infection  when  she  has  fever,  but  of  moderate  severity,  when 
the  character  of  the  pulse  remains  good,  the  heart  sounds 
clear,  and  the  heart  action  regular;  when  there  is  no  severe 
delirium  and  no  well  pronounced  stupor;  when  evidences  of 
pyemia  and  embolism  do  not  develop;  when  the  abdomen 
remains  reasonably  soft  and  without  excessive  tenderness; 
and  when  the  patient  can  take  and  assimilate  large  quantities 
of  nourishment,  iron,  arsenic,  water  and  oxygen.  The 
patient  may  be  said  to  be  resisting  poorly  when  her  temper- 
ature is  very  high  or  persistently  sub-normal;  when  the 
pulse  rises  before  the  temperature  falls;  when  the  heart 
sounds  are  not  clear  but  are  faint  or  muffled ;  when  the  heart 
action  is  weak  and  irregular;  when  the  abdomen  is  greatly 


278  MANUAL   OF   OBSTETRICS 

distended  and  very  sensitive  or  is  scaphoid  and  without 
sensation;  when  the  phenomena  of  embolism  or  thrombosis 
do  not  develop;  and  when  the  patient's  mental  and  nervous 
condition  do  not  show  great  depression  or  melancholia  or 
active  delirium.  Leukocytosis  is  of  value  as  an  indication 
of  the  patient's  power  of  resistance,  and  a  moderate  leukocy- 
tosis  is  always  a  welcome  sign.  The  detection  of  strep- 
tococci in  the  blood  has  formerly  been  considered  an  absolute 
indication  of  a  fatal  result,  but  this  conclusion  cannot  be 
accepted  as  universally  correct,  and  patients  occasionally 
recover,  although  this  condition  be  present. 

Puerperal  Septic  Infection  From  Pre-existing  Foci. — If  a 
patient  who  has  had  salpingitis  or  appendicitis  or  other  local 
infection  in  the  pelvis  or  lower  abdomen  conies  into  labor, 
the  mechanical  disturbance  caused  by  labor  may  rupture 
this  focus,  setting  free  pathogenic  bacteria  and  causing  the 
development  of  infection.  In  the  puerperal  period  an  infec- 
tion may  have  become  localized  and  remain  quiescent  and 
be  set  free  by  the  patient's  motion  or  by  some  exertion. 

To  illustrate  the  former,  in  the  experience  of  the  writer,  a 
primipara  passed  through  a  normal  labor  under  antiseptic 
precautions.  Two  days  later  she  had  fever  and  rapid  pulse, 
for  which  no  cause  could  be  given.  On  cross-questioning  she 
finally  described  pain  about  one  of  her  upper  teeth,  which 
she  said  had  given  trouble  for  some  time  after  she  became 
pregnant.  A  dentist  was  called,  who  opened  an  abscess  in 
the  periosteum  of  the  jaw,  from  which  several  ounces  of  foul 
pus  escaped.  The  symptoms  of  septic  infection  disappeared 
and  the  patient  made  a  good  recovery.  The  pre-existing 
infection  had  caused  the  development  of  pus  formation  by 
the  disturbance  incident  to  labor. 

Another  patient  had  passed  through  normal  labor  under 
antiseptic  precautions  apparently  well,  and  had  been  al- 
lowed to  do  light  work  about  the  ward.  After  lifting  a  half- 
bucket  of  coal  she  complained  of  pain  in  the  lower  abdomen 
and  gradually  developed  symptoms  of  abdominal  infection. 
When  the  abdomen  was  opened  a  bursted  pyosalpinx  was 
found  and  beginning  general  peritonitis,  from  which  the 
patient  died. 


PUERPERAL   SEPTIC    INFECTION  279 

Diagnosis. — All  patients  during  pregnancy  should  be  in- 
spected to  ascertain  the  existence  of  any  possible  focus  of 
infection.  If  labor  has  proceeded  favorably  under  antiseptic 
precautions,  and  symptoms  of  infection  develop,  the  patient's 
entire  body  should  be  examined  as  thoroughly  as  possible  to 
determine  the  presence  of  some  localized  infection.  If 
tenderness  be  found  over  the  appendix,  operation  should 
immediately  be  done.  If  an  infected  tonsil  be  present  it 
must  be  drained,  and  any  collection  of  pus  should  at  once 
be  evacuated.  When  the  focus  can  be  found  and  extirpated, 
symptoms  of  infection  disappear  and  the  patient  goes  on  to 
recover^. 

Autoinfection. — Cases  are  occasionally  seen  where  mixed 
infection,  usually  from  the  intestine  or  from  the  blood  cur- 
rent, develops  after  labor  without  known  injury  or  direct 
contamination.  In  the  experience  of  the  writer  the  bacillus 
coli  communis  infection  of  the  intestine,  developing  after 
labor,  resulted  fatally  in  a  puerperal  case.  This  was  proved 
by  autopsy. 

Another  patient  who  had  normal  labor,  under  antiseptic 
precautions,  was  subjected  to  abdominal  section  at  the 
puerperal  period,  when  the  pelvic  organs  were  found  normal. 
The  appendix  was  removed  and  its  base  was  found  reddened 
and  swollen,  the  descending  colon  swollen,  dark  red  in  color, 
and  beneath  its  peritoneal  coat  patches  of  ulceration  could 
be  seen.  This  patient  made  a  tedious  recovery,  with  the 
use  of  gauze  drains  and  stimulation. 

Labor  occurring  in  a  pregnant  woman  suffering  from 
erysipelas,  cancer,  acute  syphilitic  ulceration  of  the  genital 
tract,  abscess  in  Bartholini's  gland,  or  infection  by  the 
typhoid  bacillus  or  pneumococcus,  may  be  followed  by  acute 
septic  infection  in  the  puerperal  period.  In  some  of  these 
cases  the  course  of  the  infection  is  rapid,  its  virulence  of  high 
degree,  and  the  result  fatal.  These  occurrences  in  no  way 
lessen  the  responsibility  of  the  obstetrician,  and  antiseptic 
precautions  should  be  universally  followed  in  all  cases  of 
pregnancy  and  labor.  Unless  some  other  cause  can  be  defi- 
nitely demonstrated,  puerperal  septic  infection  must  be 
considered  as  due  to  some  lack  of  antiseptic  precautions  or 
some  error  in  manipulation  or  in  operative  procedure. 


280  MANUAL    OF   OBSTETRICS 

The  Prophylactic  Treatment  of  Puerperal  Septic  Infec- 
tion.— The  fact  that  patients  may  develop  foci  of  infection 
during  pregnancy  is  a  most  cogent  reason  for  having  preg- 
nant patients  put  under  medical  care.  The  nose  and  throat, 
if  abnormal,  should  receive  special  and  proper  treatment, 
and  infected  foci  should  be  destroyed.  The  mouth  and 
teeth  should  be  put  in  thorough  good  order.  Any  painful 
dental  operation  should  be  avoided,  and  carious  teeth  and 
suppurative  gums  or  periosteum,  must  be  cured  before  labor. 
The  patient  should  be  put  in  the  best  possible  condition  for 
resisting  infection  by  the  proper  hygiene  of  pregnancy  and 
by  especial  attention  paid  to  her  nutrition.  If  there  is  evi- 
dence of  infection  of  the  vagina,  a  foul  discharge  or  ulcerated 
condition  of  the  mucous  membrane,  the  application  of  car- 
bolic acid,  or  nitrate  of  silver  to  ulcerated  surfaces,  followed 
by  gentle  irrigation  with  lysol,  should  be  practised.  The 
patient  should  be  warned  against  the  possibility  of  self- 
infection,  if  the  fingers  are  introduced  within  the  vagina 
during  labor.  Exhaustion  and  hemorrhage  favor  the  devel- 
opment of  infection  from  bacteria  already  within  the  birth 
canal  at  labor;  so  the  patient  must  not  be  allowed  to  become 
exhausted  and  every  precaution  must  be  taken  to  avoid 
hemorrhage. 

As  toxemic  patients  readily  develop  infection,  the  patient's 
diet  and  excretory  functions  require  attention. 

During  epidemics  of  acute  infectious  disease,  such  as 
smallpox,  vaccination  with  proper  vaccines,  or  the  pro- 
phylactic injection  of  serum,  should  be  used  as  in  the  non- 
pregnant.  The  writer  had  repeatedly  seen  antitoxin  protect 
pregnant  patients  after  exposure  to  diphtheria,  and  with 
no  bad  results  for  mother  or  fetus. 

Obstetric  Antisepsis  and  Asepsis. — On  the  advent  of  labor 
the  patient's  bowels  should  be  thoroughly  emptied  if  possible 
by  a  laxative  medicine,  followed  by  copious  irrigation  with 
normal  salt  solution,  and  care  should  be  taken  that  fecal 
matter  does  not  enter  the  vagina.  The  hair  about  the  ex- 
ternal genital  organs  should  be  shortly  trimmed  or  shaved, 
the  external  parts  thoroughly  cleansed,  and  tincture  of  green 
soap  and  warm  water  followed  by  rinsing  with  sterile  water, 
and  then  with  bichloride  of  mercury  1:4000,  or  lysol  1  per 


PUERPERAL   SEPTIC    INFECTION  281 

cent.,  should  be  employed.  When  the  urinary  bladder  is 
empty  the  region  about  the  urethra  should  be  freely  flushed 
with  an  antiseptic  solution.  During  labor  a  sterile  vulvar 
dressing  should  be  worn  and  kept  in  position  by  a  T-bandage. 

We  have  already  described  the  antiseptic  precautions  neces- 
sary in  the  conduct  of  labor.  Thorough  surgical  preparation 
of  the  hands  and  forearms  of  the  obstetrician  and  nurse,  the 
use  of  sterile  rubber  gloves,  the  wearing  of  clean  or  sterile 
operating  suits  and  sterile  gowns,  and  the  precautions  which 
would  be  taken  in  a  well  appointed  operating  room,  by 
surgeons  and  nurses,  are  all  necessary. 

During  the  expulsion  of  the  child  a  pad  of  gauze  wrung 
out  of  antiseptic  solution  should  be  placed  over  the  anus  of 
the  mother  to  prevent  bacteria  from  the  intestine  gaining  ac- 
cess to  the  birth  canal.  During  labor  the  patient  should  be 
surrounded  by  sterile  linen,  and  all  appliances  and  instruments 
employed  should  be  sterilized  by  operative  surgical  methods. 

The  Antiseptic  Treatment  of  the  Birth  Canal. — During  the 
early  years  of  antisepsis  the  effort  was  made  to  prepare  the 
birth  canal  of  the  parturient  women  for  labor  as  one  would 
prepare  the  skin  for  abdominal  section.  The  mucous  mem- 
brane of  the  vagina  was  scrubbed  with  pledgets  of  cotton 
dipped  in  an  antiseptic  solution,  and  vaginal  douches  of  an- 
tiseptic solutions  were  repeatedly  and  freely  given.  The  re- 
sult was  disappointing,  for  infection  was  not  present  in  all 
cases,  and  in  some  seemed  to  be  roused  into  activity  by  the 
measures  taken  to  prevent  it. 

When  it  is  remembered  tnat  the  vagina  and  cervix  are 
protected  against  infection  by  a  sterile  secretion  of  con- 
siderable germicidal  power,  it  will  be  obvious  that  to  remove 
it<  secretion  forcibly  and  to  wound  the  capillaries  and  lym- 
phatics and  the  mucous  membrane,  must  tend  to  produce 
infection  and  not  to  prevent  it;  so  in  healthy  patients  no 
vaginal  douche  or  interference  should  be  practised  during  the 
early  stages  of  labor.  The  birth  canal  should  be  disturbed 
as  little  as  possible  by  vaginal  examinations,  and  these  should 
be  made  with  the  gloved  hand  as  gently  as  possible.  If  there 
has  been  considerable  vaginal  catarrh  during  pregnancy  a 
very  gentle  irrigation  of  1  per  cent,  lysol  may  be  given  be- 
fore the  membranes  rupture. 


282  MANUAL    OF   OBSTETRICS 

In  prolonged  and  difficult  labor  especial  attention  must  be 
given  to  prophylactic  antisepsis.  External  cleansing  should 
be  repeated  by  flushing  with  an  antiseptic  solution  before 
and  after  each  examination  or  manipulation.  No  vaginal 
delivery  should  be  attempted  unless  the  cervix  is  dilated  or 
easily  dilatable,  and  those  methods  of  delivery  should  be 
chosen  which  inflict  the  least  traumatism  upon  the  mother. 
The  prompt  closure  of  lacerations  under  antiseptic  precau- 
tions after  labor,  is  important  in  preventing  infection. 

Obstetric  Asepsis.— By  obstetric  asepsis  is  meant  the 
strict  enforcement  of  the  rule  that  nothing  that  has  not  been 
sterilized  should  be  allowed  to  touch  the  genital  tract  of  the 
patient  during  labor.  While  the  application  of  strong  anti- 
septic solutions  to  the  birth  canal  is  a  mistake,  still  there  is 
no  exception  to  the  rule  of  asepsis.  So  sterile  linen  and  ster- 
ile appliances  and  sterile  dressings  with  sterile  gowns  and 
gloves  and  instruments  and  suture  material,  and  the  knowl- 
edge that  in  the  healthy  woman  the  birth  canal  is  practically 
sterile  and  requires  no  interference,  has  greatly  lessened 
puerperal  mortality  and  morbidity. 

The  Treatment  of  Puerperal  Septic  Infection. — So  soon  as 
this  condition  occurs  the  first  duty  of  the  obstetrician  is 
to  see  that  no  infective  material  has  been  retained  within 
the  uterus.  For  this  purpose  the  uterine  cavity  should  be 
very  gently  explored  by  the  fingers  of  the  gloved  hand,  or 
better,  by  gentle  irrigation  with  normal  salt  solution,  or  1 
per  cent,  lysol,  through  a  hollow  stemmed,  blunt  edged  cu- 
rette. This  should  be  used  simply  as  a  long  finger  to  pass 
gently  over  the  lining  of  the  uterus  and  bring  away  any 
loosened  bit  of  placenta  or  membranes.  Under  no  circum- 
stances should  vigorous  and  thorough  curetting  with  a  sharp- 
edged  instrument  be  undertaken 

If  this  simple  manipulation  causes  free  hemorrhage  the 
uterine  cavity  should  be  thoroughly  packed  with  10  per  cent, 
iodoform  gauze.  It  is  also  essential  that  the  intestinal  tract 
be  emptied  as  promptly  and  thoroughly  as  possible.  A  com- 
bined cathartic  pill,  followed  by  repeated  small  doses  of 
salines,  gives  good  results.  A  copious  irrigation  of  the  colon 
with  hot  normal  salt  solution  should  be  given.  If  lacerations 
have  been  closed  by  suture,  such  sutures  should  be  removed 


PUERPERAL   SEPTIC    INFECTION  283 

and  the  wound  allowed  to  gape  open  and  painted  with  tinc- 
ture of  iodine  or  irrigated  with  1  per  cent,  lysol.  To  secure 
good  contraction  of  the  uterus,  tonic  doses  of  strychnia  and 
ergot  are  necessary.  For  abdominal  pain  a  turpentine  stupe 
and  dry  ice  bag  give  good  results. 

Food  and  Stimulants. — To  combat  successfully  puerperal 
septic  infection,  the  mother  requires  an  abundant  supply  of 
the  most  nutritious  and  digestible  food.  Milk  in  every  di- 
gestible form  and  sometimes  pancreatised,  beef  juice,  barley, 
oat  or  wheat  jelly,  chicken  jelly,  junket,  orange,  lemon,  grape 
fruit  or  pineapple  albumen,  the  juices  of  these  fruits  with 
the  white  of  an  egg,  will  be  found  useful.  Liquid  food  every 
two  to  three  hours,  an  abundant  supply  of  good  drinking 
water  or  Celestin  Vichy,  are  important. 

If  stimulants  are  required,  it  must  be  remembered  that  al- 
cohol is  not  a  stimulant.  Strychnia  and  digitalin  are  the 
most  valuable  stimuli  which  we  possess  for  this  condition. 
This  may  be  given  every  four  to  six  hours  with  nourishment. 
To  this  may  be  added  for  septic  patients  who  are  anemic, 
tincture  of  chloride  of  iron  in  doses  ranging  from  5  to  30 
drops  well  diluted.  Alcohol  should  be  used,  if  needed  as  a 
sedative,  to  produce  sleep  and  to  spare  the  body  of  the 
patient  from  excessive  waste.  The  best  quality  of  whiskey 
or  brandy  well  diluted,  in  doses  varying  from  one-half  ounce 
to  an  ounce,  should  be  given  in  the  afternoon  and  night.  If 
the  patient  be  accustomed  to  tea  and  coffee,  a  moderate 
quantity  of  this  will  not  do  harm. 

The  Reduction  of  Temperature. — The  temperature  in  puer- 
peral sepsis  should  not  be  reduced  unless  it  seems  to  oppress 
the  patient.  A  dry  ice  bag  upon  the  abdomen  and  sponging 
are  useful,  and  gentle  rubbing  with  alcohol  is  soothing  to 
the  patient. 

As  the  temperature  is  an  index  of  the  patient's  effort  to  re- 
sist, a  temperature  of  from  100  to  102°  F.  is  of  better  import 
than  a  continual  subnormal  temperature. 

Specific  Medication. — If  the  uterine  lochia  be  obtained  with- 
out contamination  and  found  to  be  rich  in  streptococci,  the 
use  of  antistreptococcic  serum  would  seem  indicated.  Ex- 
perience shows  that  in  some  cases  antistreptococcic  serum  is 
followed  by  prompt  improvement,  while  in  others  it  pro- 


284  MANUAL    OF   OBSTETRICS 

(luces  no  effect.  Where  diphtheritic  infection  complicates 
the  puerperal  state  antitoxin  has  given  good  results.  Where 
mixed  infections  are  present  vaccines  may  be  prepared  and 
are  used  by  many  with  considerable  success.  It  is  too  soon 
as  yet  to  know  their  absolute  value.  Remedies  which  tend 
to  increase  leukocytosis,  as  nuclein,  have  been  useful  in  some 
cases. 

Increasing  the  Patient's  Resistance  to  Sepsis.— While  the 
use  of  nutritious  material  is  of  the  utmost  importance,  this 
may  be  supplemented  by  other  methods  of  treatment.  To 
dilute  the  toxins  in  the  blood,  and  to  stimulate  the  secretion 
of  the  bowels  and  kidneys,  salt  solution  may  be  given  by  the 
drip  method.  The  establishment  of  what  is  termed  fixation 
abscess  seems  of  value  in  some  cases  and  seems  to  cause  an 
increased  production  of  immunizing  material.  Inunction 
with  Crede's  silver  ointment  apparently  operates  in  the  same 
manner.  In  desperate  cases  direct  transfusion  of  blood  has 
been  of  value. 

The  Nervous  System  in  Puerperal  Septic  Infection. — 
It  is  of  the  utmost  importance  that  nothing  be  done  in  the 
treatment  of  puerperal  septic  infection  to  depress  the  ner- 
vous system.  Thus  antipyretic  drugs  should  never  be  used. 
A  temperature  so  high  as  to  depress  the  patient  should  be 
reduced  by  cold,  while  the  nervous  system  is  protected  by 
alcohol  used  as  a  sedative.  An  abundance  of  pure  air  or  the 
inhalation  of  oxygen  is  valuable  for  the  nervous  system. 

Where  pain  cannot  be  controlled  by  counter-irritation 
and  cold,  and  where  the  patient  is  becoming  hectic,  morphia 
hypodennatically  is  valuable.  The  mental  condition  of  the 
patient  should  not  be  disturbed  by  noise  or  excitement,  while 
the  mind  should  be  stimulated  by  a  hopeful  atmosphere. 

Nursing  in  Puerperal  Septic  Infection. — This  is  a  most 
valuable  adjunct  in  the  care  of  the  patient.  A  skilful  nurse 
can  do  more  than  any  other  person  to  guard  the  resisting  power 
of  the  patient.  In  long-continued  cases,  the  prevention  of 
bed-sores,  the  care  of  the  skin,  the  careful  feeding  of  the  pa- 
tient, the  judicious  use  of  alcohol,  the  procuring  of  a  constant 
supply  of  fresh  air,  are  matters  of  the  greatest  importance. 
Written  orders  should  be  given  by  the  attending  obstetrician, 
and  written  and  detailed  reports  and  charts  kept  by  the 


PUERPERAL   SEPTIC    INFECTION  285 

nurse.  A  summary  of  the  nourishment,  stimulus  and  alco- 
hol taken  during  the  twenty-four  hours  should  be  prepared. 
Severe  cases  require  several  nurses  with  unremitting  atten- 
tion to  sustain  the  strength  of  the  patient. 

Nurses  must  be  warned  against  the  danger  of  personal 
infection  through  abrasions  in  the  hands,  and  rubber  gloves 
should  be  worn  in  cleansing  the  genital  organs  of  the  patient 
and  in  changing  her  clothing. 

No  nurse  should  go  directly  from  a  septic  to  a  clean  case, 
but  abundant  time  should  be  taken  to  thoroughly  sterilize 
all  clothing  and  personal  belongings,  to  take  frequent  anti- 
septic baths,  to  have  the  hair  thoroughly  washed,  and  made 
aseptic,  and  to  spend  considerable  time  in  the  open  air. 

The  Surgical  Treatment  of  Puerperal  Septic  Infection. — 
The  hopes  of  the  profession  were  at  first  considerably  raised 
by  the  belief  that  prompt  hysterectomy  would  save  many 
cases  of  puerperal  septic  infection.  Unfortunately,  when  a 
positive  decision  to  operate  can  be  made  the  infective  bac- 
teria have  long  since  passed  from  the  uterus  into  the  blood 
stream  of  the  patient's  general  circulation.  Hence  hyster- 
ectomy has  been  largely  abandoned  except  in  cases  of  slough- 
ing and  infected  fibroid  tumors  or  suppurating  ovarian  cysts. 
Ligation  of  the  veins  of  the  broad  ligaments  has  likewise 
found  supporters,  but  again  this  process  must  be  viewed  as  a 
conservative  one  on  the  part  of  nature  to  prevent  further 
spread  of  infectious  bacteria.  Hence  the  majority  believe 
that  these  thrombosed  veins  should  be  let  alone. 

Concerning  the  opening  and  draining  of  collections  of  pus 
complicating  puerperal  septic  infection,  there  can  be  no  doubt. 
This  procedure  is  based  upon  general  surgical  grounds  and  is 
universally  adopted.  This  would  naturally  include  the  re- 
moval of  a  pyosalpinx,  if  such  could  be  diagnosticated. 

Where  the  pelvic  peritoneum  and  Fallopian  tubes  are  in- 
volved in  septic  infection  good  results  have  been  obtained  by 
opening  the  abdomen,  loosening  pelvic  adhesions,  removing 
pus  tubes,  and  opening  the  posterior  vaginal  vault.  The 
pelvic  organs  are  replaced  in  as  nearly  as  possible  their  nat- 
ural position,  and  the  pelvic  cavity  behind  them  is  filled  with 
10  per  cent,  iodoform  gauze.  The  posterior  vault  of  the 
vagina  is  then  freely  opened  and  the  gauze  passed  downward 


286  MANUAL   OF   OBSTETRICS 

into  the  vagina.  The  abdomen  is  then  completely  closed 
and  the  gauze  gradually  removed  from  below. 

Pryor's  method  for  this  condition  consisted  in  opening  the 
posterior  vaginal  fornix  very  freely  from  side  to  side.  Ad- 
hesions were  separated  as  far  as  possible  by  the  gloved  fingers, 
and  small  collections  of  pus  were  opened  by  this  method. 
The  uterus  was  carried  upward  and  the  cervix  backward; 
iodoform  gauze  was  then  introduced  through  the  vagina  to 
carry  backward  the  intestines  and  to  thoroughly  drain  the 
pelvic  cavity. 

These  procedures  have  much  in  common  and  are  con- 
servative in  their  nature. 

Complications  of  Puerperal  Septic  Infection. — Mastitis 
and  breast  abscess  not  infrequently  accompany  puerperal 
septic  infection.  In  all  cases  of  sepsis  the  child  must  be 
taken  from  the  breast.  The  infected  breast  should  be  immob- 
ilized by  a  dry  ice  bag  placed  over  the  infected  area  and  a 
broad  breast  bandage.  If  there  is  much  pain,  lead  water 
and  laudanum  may  be  applied  under  the  ice  bag.  If  the 
infection  does  not  subside,  incision  and  drainage  are  neces- 
sary. Multiple  joint  abscesses  may  complicate  the  re- 
covery of  the  patient  with  puerperal  septic  infection.  These 
must  be  opened  and  drained  as  the  conditions  require.  Sep- 
tic pleurisy  may  require  aspiration  of  purulent  fluid  from 
the  thorax. 

Thrombosis  and  Embolism. — The  external  saphenous  vein 
and  sometimes  the  deeper  veins  of  the  body  may  become 
plugged  by  septic  thrombi  during  the  puerperal  period.  In 
the  case  of  the  thigh  the  limb  must  be  elevated,  lead  water 
and  laudanum  and  an  ice  bag  applied  over  the  site  of  the 
thrombus,  and  should  infection  of  the  skin  occur,  with  sup- 
puration, this  should  be  drained  by  multiple  long  incisions. 
Where  foci  of  infection  develop  in  the  internal  organs  the  in- 
fection may  be  disseminated  by  multiple  embolism,  which 
may  plug  the  retinal  artery,  causing  blindness,  or  produce  the 
death  of  the  patient  by  pulmonary  embolism. 

Convalescence  from  Puerperal  Septic  Infection. — This 
will  depend  upon  the  vigor  of  the  patient  and  the  treatment 
which  she  receives.  In  ill-developed  and  ill-nourished  prirni- 
para3  and  in  multipart  exhausted  by  frequent  childbirth, 


PUERPERAL   SEPTIC    INFECTION  2M 

septic  infection  may  rapidly  proceed  to  a  fatal  termination. 
On  the  other  hand,  some  of  the  most  desperate  cases  recover 
under  skilful  and  constant  care. 

The  period  of  convalescence  varies  in  accordance  with 
the  severity  of  the  infection  and  the  resisting  power  of  the 
patient.  Several  months  may  be  required  before  the  patient 
regains  her  strength,  and  in  some  cases  her  former  health 
never  returns. 

Septic  Infection  Attacking  the  Fetus  during  Pregnancy. — 
Infective  bacteria  may  gain  access  to  the  fetus  during  preg- 
nancy through  the  blood  stream  of  the  mother,  or  through 
the  placenta,  or  through  the  amniotic  liquid.  Typical  ex- 
amples of  the  first  are  blood  stream  infection,  as  seen  in 
acute  infective  diseases.  In  typhoid,  in  pneumonia,  malaria, 
syphilis,  and  other  acute  infections,  the  fetus  shares  the 
mother's  disease.  Thus,  a  fetus  expelled  during  these  dis- 
eases will  be  found  to  contain  infective  germs  and  to  have  the 
characteristic  lesions.  In  fetal  infection  from  the  mother's 
blood,  obviously  the  only  means  of  treatment  lies  in  remedies 
administered  to  the  mother.  It  is  impossible  to  treat  the 
fetus  separately,  and  all  that  can  be  done  is  to  treat  the 
mother  in  the  most  efficient  manner  possible. 

In  estimating  the  dose  of  antitoxins  or  sera  given  to  preg- 
nant women  it  is  well  to  use  these  remedies  in  full  doses,  for 
thus  the  fetus  will  receive  the  greatest  benefit.  The  inter- 
ruption of  pregnancy  in  the  interests  of  the  fetus  is  not  ad- 
visable, for  it  can  best  be  treated  through  the  medium  of  the 
mother's  blood,  and  its  chance  of  recovery  is  best  if  it  re- 
mains in  the  mother's  womb. 

Unquestionably  the  placenta  has  the  function  of  disposing 
of  a  considerable  quantity  of  infective  bacteria  in  the  pro- 
tection of  the  fetus.  How  great  this  protective  power 
may  be  in  a  given  case  cannot  be  accurately  estimated. 
Also  the  youth  and  general  vigor  of  the  mother  indicate 
the  healthy  placenta  and  good  protecting  power  from 
this  organ;  and,  on  the  contrary,  a  multipara  exhausted 
by  frequent  child-bearing,  or  a  primipara  much  above  the 
average  age,  will  furnish  poor  placental  protection.  Evi- 
dence of  the  success  or  failure  of  this  function  of  the  placenta 
is  found  in  characteristic  lesions  and  the  disease  observed  in 


288  MANUAL    OF    OBSTETRICS 

the  placenta  after  birth.  Microscopic  examination  in  these 
cases  will  demonstrate  the  presence  of  the  infective  germ, 
and  in  severe  cases  characteristic  alterations  in  the  blood 
vessels  of  the  placental  tissue. 

During  pregnancy  infective  bacteria  may  make  their 
way  into  the  cervix,  and  in  some  instances  penetrate  the 
fetal  membranes.  The  amniotic  liquid  may  thus  become 
infected  and  may  be  swallowed  by  the  fetus,  causing  infec- 
tion of  the  gastro-intestinal  tract.  Such  infective  bacteria 
have  been  demonstrated  in  the  amniotic  liquid  and  are  un- 
doubtedly a  cause  of  infection  of  the  maternal  peritoneum  in 
cases  of  delivery  by  Cesarean  section. 

The  prevention  of  this  condition  lies  in  cleanliness  on  the 
part  of  the  patient  during  pregnancy  and  in  the  avoidance 
of  vaginal  examinations  and  manipulation  by  infected  hands 
or  appliances.  We  have  no  direct  method  of  treating  this 
complication. 

Inspiration  Pneumonia. — After  the  membranes  have  rup- 
tured, infective  bacteria  from  the  vagina  may  make  their 
way  into  the  fetal  sac,  and  if  the  fetus  makes  respiratory 
movements,  may  enter  its  air  passages.  This  is  one  of  the 
dangers  incident  to  long  labor  with  ruptured  membranes, 
and  to  those  manipulations,  such  as  version,  which  may 
introduce  infective  bacteria  into  the  fetal  sac  and  excite 
involuntary  respiratory  fetal  movements. 

The  symptoms  of  inspiratory  pneumonia  in  the  new-born 
originating  in  utero,  are  fever,  rapid  pulse,  acute  toxemia, 
and  death.  The  lungs  of  the  newborn  child  do  not  unfold 
normally,  its  breathing  remains  tubular,  the  lungs  remain  dull 
on  percussion,  and  unnatural  breath  sounds  can  sometimes 
be  detected. 

The  treatment  of  inspiration  pneumonia  in  the  newborn 
is  entirely  stimulating  and  tonic.  The  free  use  of  oxygen, 
small  doses  of  strychnia,  digitalin,  and  atropin,  given  hypo- 
dermatically,  and  the  careful  use  of  dry  cold  over  the  chest, 
are  indicated. 

To  combat  the  toxemia  which  develops,  free  flushing  of  the 
intestine  with  equal  parts  of  sterile  salt  solution  and  boiled 
water,  is  indicated.  If  the  child  can  swallow  and  assimilate 
the  breast  milk  its  chance  for  recovery  is  greatly  improved. 


PUERPERAL   SEPTIC    INFECTION  289 

If  this  is  not  the  case  the  prognosis  is  always  exceedingly 
grave.  The  disease  does  not  run  a  typical  course,  for  pneu- 
monia, but  its  duration  and  severity  depend  upon  the  vari- 
ety and  number  of  the  infective  bacteria. 

While  the  active  treatment  of  inspiration  pneumonia 
is  often  unsuccessful,  much  can  be  done  to  avoid  this  condi- 
tion. Strict  antisepsis  in  the  condition  of  labor,  the  use  of 
rubber  gloves  in  obstetric  operations,  thorough  dilatation  of 
the  cervix  before  attempting  vaginal  delivery,  the  avoidance 
of  unnecessary  manipulation  and  disturbance  during  vaginal 
delivery,  and  the  use  of  sterile  vulvar  dressings  during  pro- 
longed labor,  are  all  useful. 

In  Cesarean  section  with  unbroken  membranes,  the  am- 
niotic  liquid  should  be  emptied  at  the  moment  of  operation 
as  completely  as  possible  before  the  child  is  extracted.  Re- 
membering the  infective  nature  of  this  fluid,  it  is  safer  to  de- 
liver the  child  with  the  uterus  turned  out  of  the  abdomen 
than  by  allowing  it  to  remain  in  situ. 

Septic  Infection  in  the  Newborn. — If  the  fetus  has  shared 
the  mother's  septic  infection  during  long  and  difficult  labor 
it  will  develop  characteristic  symptoms  of  this  condition  after 
birth.  Inspiration  pneumonia  may  be  the  predominant  form 
of  infection.  If  blood  infection  be  present,  fever,  rapid 
pulse,  prostration,  inability  to  nurse,  dark  red  fluid  discharges 
from  the  bowels  and  petechial  skin  eruptions,  may  be  present. 
If  the  blood  be  examined  the  infective  germ  may  be  dis- 
covered. 

Although  the  child  may  be  born  without  infection,  if  the 
mother  develops  sepsis  the  child  may  share  her  disease.  If 
the  fingers  of  the  nurse  are  infected,  in  bathing  the  child 
she  may  infect  its  mouth,  or  the  stump  of  the  umbilical  cord. 
If  the  child's  head  has  been  bruised  and  lacerated  by  forceps, 
scalp  wounds  so  caused  may  become  infected.  The  signs 
and  symptoms  of  this  condition  are  redness,  swelling,  and 
tenderness  over  and  about  the  infected  areas  with  the  for- 
mation of  a  purulent  secretion,  or  a  crust  containing  pus  cells, 
fibrin  and  infective  bacteria.  If  the  fingers  of  the  nurse  have 
not  been  sterile  at  the  birth  of  the  child,  and  these  fingers 
have  been  introduced  into  the  mouth  to  cleanse  it,  the  mouth 
may  become  infected.  If  the  child  has  swallowed  infective 
19 


290  MANUAL    OF   OBSTETRICS 

bacteria  in  utero,  or  infected  milk  from  the  mother's  breast, 
enteritis  may  develop  with  dark  fluid  discharges  from  the 
bowels.  If  the  milk  be  infected,  the  tissues  at  the  umbilical 
ring  will  be  reddened,  swollen  and  tender,  and  pus  may  de- 
velop. In  the  case  of  severe  cranial  injuries  to  the  newborn, 
if  the  fetal  blood  be  infected  and  the  child  survives  suffi- 
ciently long,  meningitis  may  be  the  result. 

In  septic  infection  developing  after  the  birth  of  the  child 
the  local  treatment  consists  in  thoroughly  cleansing  infected 
areas  with  peroxide  of  hydrogen,  and  in  the  use  of  mild  anti- 
septics, such  as  boracic  acid  in  ointment  or  powder.  Dress- 
ings of  sterile  gauze  should  be  used  and  the  infected  areas 
frequently  irrigated  and  cleansed.  The  general  treatment 
consists  in  the  use  of  stimulants,  breast  feeding  if  possible, 
intestinal  irrigation,  and  a  free  supply  of  oxygen  or  fresh  air. 

While  ordinarily  the  mother  infects  the  fetus,  if  the  child 
has  derived  its  infection  through  the  carelessness  of  the 
physician  or  nurse,  the  child  may  infect  the  mother.  This  is 
especially  true  where  there  are  cracks  and  fissures  of  the 
nipple,  and  where  the  child's  mouth  has  not  been  carefully 
cleansed  before  and  after  nursing. 

A  frequent  cause  of  infection  of  the  mouth  and  eyes  of  the 
infant  is  rough  and  careless  methods  of  cleansing  at  the  time 
of  birth.  So  soon  as  the  head  is  born  the  eyelids  and  orbital 
regions  should  be  very  gently  but  thoroughly  cleansed  with 
soft  sterile  linen,  and  a  sterile  solution  of  boracic  acid.  As  a 
prophylactic  against  the  development  of  eye  infection, 
argyrol  or  nitrate  of  silver  can  be  dropped  into  each  eye.  In 
cleansing  the  mouth  boric  solution  should  be  employed  and 
a  clean  finger  covered  with  soft  sterile  linen  dipped  in  boric 
solution  should  be  used  with  the  utmost  gentleness  to 
cleanse  the  mouth  and  remove  any  mucus,  blood,  or  vaginal 
secretion,  which  may  have  entered  the  child's  mouth  during 
birth 


PART  IV 
THE  NORMAL  PUERPERAL  PERIOD 


CHAPTER  XV 
THE  MOTHER 

The  puerperal  period  begins  so  soon  as  the  fetus  and  its 
appendages  have  been  expelled  or  removed  from  the  uterus. 
Its  essential  phenomena  are  involution  of  the  uterus,  whereby 
it  returns  to  very  nearly  its  original  size  and  shape,  the  in- 
volution and  contraction  of  the  pelvic  floor,  abdominal 
muscles  and  other  muscles  concerned  in  parturition,  the 
successful  establishment  of  lactation,  and  the  readjustment 
of  the  mother's  organs  of  assimilation  and  digestion,  to  the 
conditions  altered  by  the  birth  of  the  infant.  In  other  words, 
the  mother  during  the  puerperal  period  should  return  very 
nearly  to  her  condition  before  impregnation. 

INVOLUTION 

By  the  intermittent  contraction  of  its  muscle  fibres  the 
uterus  grows  progressively  smaller.  Immediately  after  the 
expulsion  of  the  placenta  it  relaxes,  so  that  the  fundus  is 
usually  at  the  umbilicus.  If  the  uterine  sinuses  have  been 
normally  occluded  by  thrombi  this  is  not  accompanied  by 
bleeding.  In  normal  cases  the  uterus  begins  to  contract 
when  the  child  is  put  to  the  breast,  and  lactation  and  nursing 
are  a  powerful  stimulus  to  involution.  The  rate  of  involu- 
tion will  depend  upon  the  absence  of  infection,  the  mother's 
ability  to  nurse  the  child,  and  her  general  vigor.  Septic  in- 
fection delays  involution,  infective  bacteria  swarming  be- 
tween muscle  bundles,  thus  choking  the  lymphatics  of  the 

291 


292  MANUAL    OF    OBSTETRICS 

uterus  and  preventing  its  normal  circulation.  The  muscular 
tissue  is  softened  by  the  toxins  which  infective  bacteria 
produce.  Thus  an  index  of  the  success  of  involution  is 
found  in  the  absence  of  infection. 

Those  drugs  and  remedies  which  stimulate  uterine  con- 
traction through  direct  influence  upon  the  uterine  muscle 
or  stimulation  of  the  nervous  ganglia  of  the  uterus,  favor 
involution.  The  normal  position  of  the  womb,  which  permits 
the  free  discharge  of  the  lochia,  is  essential  for  good  involu- 
tion. Lacerations  of  the  cervix  hinder  involution  because 
they  permit  the  entrance  of  bacteria,  and  may  extend  suffi- 
ciently far  to  injure  the  ligaments  which  keep  the  womb  in 
normal  position. 

LOCHIAL  DISCHARGE 

This  is  first  blood  and  serum  from  uterine  sinuses  and  after- 
ward serous  fluid  containing  the  debris  of  the  uterine  decidua, 
and  later  mucous  from  crypts  in  the  vaginal  mucous  mem- 
brane, and  from  the  cervix.  The  lochial  discharge  is  some- 
times called  the  bloody,  serous  and  mucous  lochia.  Its 
amount  varies  with  the  amount  of  laceration  of  the  uterus  and 
the  general  condition  of  the  uterine  muscle.  The  color  of  the 
lochial  discharge  and  its  character  may  be  greatly  altered  by 
infection,  as  is  the  case  with  streptococcus  infection  when  the 
lochial  discharge  is  a  thin  dark  brownish-red  and  inodorous 
fluid. 

The  odor  of  the  lochial  discharge  depends  upon  the  kind 
of  bacteria  which  it  contains.  If  staphylococci  be  present 
in  abundance  they  are  usually  accompanied  by  leukocytes, 
and  the  lochial  discharge  has  the  characteristic  odor  of  pus. 
While  foul  smelling  lochia  is  offensive,  it  rarely  indicates 
a  condition  of  danger.  In  the  most  serious  infection,  that 
of  streptococcus,  the  lochial  discharge  has  but  little  if  any 
odor. 

The  Cessation  of  the  Lochial  Discharge.— This  depends 
upon  the  amount  and  degree  of  laceration  of  the  generative 
tract  present,  the  degree  of  uterine  and  vaginal  involution, 
the  establishment  of  lactation,  or  the  occurrence  of  infection. 
When  lactation  is  developing  the  lochial  discharge  is  greatly 
diminished  and  may  remain  less  than  normal  for  from  twenty- 


LOCHIAL   DISCHARGE  293 

four  to  thirty-six  hours.  The  explanation  of  this  phenomenon 
is  found  in  the  fact  that  the  formation  of  milk  in  the  breast 
produces  a  temporary  toxemia.  This  seems  to  inhibit  the 
formation  and  discharge  of  the  lochia  and  usually  causes  dis- 
turbance in  the  patient's  pulse,  temperature  and  nervous 
system.  As  the  secretion  of  milk  becomes  established  the 
lochial  discharge  returns. 

The  lochial  discharge  of  an  apparently  healthy  mother 
may  prove  infective  to  another  organism,  so  physicians  and 
nurses  having  scratches  upon  the  hands  have  become  in- 
fected from  attendance  upon  puerperal  patients. 

Diagnosis  by  the  Examination  of  the  Lochial  Discharge. — 
An  attempt  has  been  made  in  puerperal  septic  infection  to 
diagnosticate  the  kind  and  severity  of  the  infection  by  ex- 
amining the  lochia.  While  it  is  a  comparatively  simple 
matter  to  isolate  streptococci,  staphylococci,  bacillus  coli 
communis,  and  other  less  important  germs  from  the  lochial 
discharge,  the  presence  of  these  germs  does  not  necessarily 
prove  that  the  infection  is  a  severe  or  dangerous  one.  Pa- 
tients often  give  no  constitutional  sign  of  infection  although 
germs  are  found  in  the  lochial  discharge. 

In  pursuing  this  study,  the  uterine  lochia  only  should  be 
taken,  and  every  possible  precaution  be  exercised  to  avoid 
contamination  with  the  vaginal  lochia. 

The  Treatment  of  the  Lochial  Discharge  During  the 
Puerperal  Period. — Upon  the  establishment  of  antisepsis  it 
was  thought  necessary  to  wash  away  the  lochial  discharge 
by  copious  vaginal  antiseptic  douches.  The  results  of  this 
treatment  were  disastrous,  for  bacteria  from  the  vagina  were 
carried  by  the  douche  fluid  into  the  uterine  cavity  and  in- 
fection was  increased  rather  than  lessened.  Since  vaginal 
douches  have  been  abandoned  the  percentage  of  puerperal 
mortality  and  morbidity  has  been  reduced.  To  receive  the 
lochial  discharge  antiseptic  occlusion  dressings  should  be 
worn  over  the  vulva.  These  should  be  composed  of  sterile 
material  and  there  is  an  advantage  in  having  it  soaked  in 
antiseptic  fluid.  This  prevents  the  growth  of  bacteria  in 
the  dressing  and  lessens  somewhat  the  patient's  chance  of 
local  reinfection.  Such  dressings  should  be  burned  after 
removal,  as  they  become  a  source  of  danger  if  allowed  to  re- 


294  MANUAL    OF    OBSTETRICS 

main  long  in  the  patient's  room  or  in  the  wards  of  the  hos- 
pital. 

To  cleanse  the  patient  from  the  lochial  discharge  when 
the  dressings  are  changed,  a  copious  irrigation  by  a  small 
pitcher  with  an  antiseptic  solution  is  the  most  efficient  and 
safe  method.  Where  the  lochia  is  offensive  especial  care 
should  be  exercised  to  change  the  dressings  frequently  and  to 
keep  the  patient  as  clean  as  possible  by  external  douching. 
If  this  precaution  be  taken  but  little  odor,  if  any,  will  be  per- 
ceptible about  the  patient. 

THE  INVOLUTION  OF  THE  GENITAL  TRACT  ASIDE  FROM  THE 

UTERUS 

The  distended  tissues  of  the  pelvic  floor  and  perineum  and 
the  over-stretched  muscles  and  fascia  of  the  abdomen  grad- 
ually recover  very  nearly  their  previous  condition.  Patients 
usually  have  great  faith  in  a  tight  bandage  to  secure  con- 
traction of  the  abdominal  muscles.  This  virtually  puts 
these  muscles  in  splints  and  it  is  far  inferior  to  efficient 
massage  and  graduated  movements.  Such  may  be  under- 
taken after  the  second  week  of  the  puerperal  period  with 
great  advantage. 

Normally  the  uterus  returns  to  practically  its  former  size, 
shape  and  position. 

To  prevent  retroversion  in  the  puerperal  period  the 
mother  must  not  lie  constantly  upon  her  back,  but  must 
turn  frequently  upon  tKe  sides  or  even  upon  the  abdomen. 
The  rate  of  uterine  involution  should  be  watched  during  the 
puerperal  period  by  observing  the  distance  of  the  fundus 
from  the  symphysis  pubis.  In  a  primipara  the  fundus  should 
have  reached  the  pelvic  brim  in  from  ten  to  fourteen  days 
after  childbirth.  In  a  multipara  the  uterus  remains  perma- 
nently enlarged  and  the  fundus  correspondingly  higher  in  the 
abdomen.  If  there  is  a  tendency  to  retroversion  during  the 
puerperal  period  the  simplest  and  most  efficient  method  of 
treatment  consists  in  having  the  patient  lie  upon  the  sides  or 
abdomen,  and  after  the  first  two  weeks  in  having  her  assume 
the  knee-chest  posture  for  ten  minutes,  night  and  morning. 
The  nurse  should  open  the  vulva  sufficiently  to  permit  the 
free  entrance  of  air. 


RETURN   OF   PATIENT  TO   NORMAL   CONDITION  295 

THE  RETURN  OF  THE  PATIENT  TO  HER  NORMAL  CONDITION 
OF  ASSIMILATION  DURING  THE  PUERPERAL  PERIOD 

Immediately  after  birth  the  mother  is  too  exhausted  to 
take  much  nourishment  and  desires  rest  most  of  all.  She 
should,  if  possible,  obtain  several  hours  of  uninterrupted 
sleep.  When  this  is  over,  the  child  should  be  put  to  the 
breast  to  stimulate  the  secretion  of  milk.  Her  first  desire 
will  be  to  gratify  thirst,  when  water  should  be  taken  freely 
during  the  puerperal  period.  The  first  food  taken  should  be 
milk  and  other  nutritious  liquids,  and  the  juice  of  ripe  fruit. 
At  labor  the  intestines  are  over-distended  with  fecal  matter 
in  the  colon  and  the  bowels  are  often  paretic  and  distended 
with  gas.  The  bowels  should  be  caused  to  move  thoroughly. 
In  bringing  about  this  result  the  influence  of  laxatives  and 
purgatives  upon  lactation  must  be  remembered.  Salines 
tend  to  lessen  the  secretion  of  milk  and  to  make  the  tension  in 
the  breasts  less.  Active  purgation  also  diminishes  the  se- 
cretion of  milk.  The  milder  laxatives,  such  as  cascara  sa- 
grada  and  compound  licorice  powder,  decrease  the  secretion 
of  milk  very  little  if  any.  Castor  oil  also  disturbs  lactation 
very  little.  Cascara  is  occasionally  observed  to  cause  irri- 
tation in  the  infant's  bowels  but  this  disappears  upon  les- 
sening the  dose. 

In  administering  laxatives  and  purgatives  after  labor,  if 
the  patient  has  had  a  copious  irrigation  just  before  labor,  the 
second  or  third  day  may  be  chosen  as  the  time  to  move  the 
bowels.  Meanwhile  should  gas  annoy,  and  distention  oc- 
cur, a  high  copious  enema  or  saline  irrigation  will  give  re- 
lief. Should  the  breasts  become  excessively  distended  a 
compound  cathartic  pill,  followed  by  a  saline,  will  often  lessen 
mammary  tension  considerably.  If,  however,  the  secretion 
of  milk  is  scanty  the  bowels  may  remain  undisturbed  until 
the  third  day,  when  a  mild  laxative  should  be  used  to  secure 
a  first  evacuation.  During  the  puerperal  period  the  patient's 
bowels  should  move  daily  with  the  mildest  efficient  laxative 
and  with  irrigation  if  necessary. 

As  pregnant  patients  often  suffer  from  hemorrhoids,  purg- 
atives may  be  selected  with  reference  to  this  condition. 
These  hemorrhoids  usually  become  worse  on  the  fourth  or 
fifth  day  after  labor  and  may  greatly  disturb  the  patient. 


296  MANUAL    OF    OBSTETRICS 

(Jnder  these  conditions  warm  olive  oil  should  be  injected 
into  the  bowel  before  each  movement,  the  region  about  the 
anus  should  be  thoroughly  but  gently  cleansed  by  irrigation 
with  1  per  cent,  lysol  mixture,  and  hot  or  cold  applications 
of  1  per  cent,  lysol,  or  lead  water  and  laudanum  may  be 
used.  If  the  bowels  be  moved  several  days  with  aloes, 
strychnia,  and  belladonna,  a  good  result  will  be  obtained  from 
these  remedies. 

THE  URINE  DURING  THE  PUERPERAL  PERIOD 

Immediately  after  labor  the  urine  of  the  puerperal  patient 
is  often  highly  colored,  loaded  with  urates,  and  may  contain 
some  albumin.  As  she  recovers  from  the  muscular  strain 
of  labor  the  urates  and  coloring  matter  disappear  from  the 
urine  and  it  becomes  practically  normal.  It  is  usually  con- 
taminated by  the  lochial  discharge,  and  if  it  is  necessary  to 
examine  it,  it  must  be  obtained  by  catheter. 

The  Functions  of  the  Urinary  Bladder. — During  the  early 
and  the  late  months  of  pregnancy  patients  are  usually  an- 
noyed by  the  pressure  of  the  uterus  or  of  the  fetal  head  upon 
the  bladder.  Frequent  and  painful  micturition  is  often  a 
consequence.  The  bladder  may  not  be  completely  emptied 
and  may  remain  in  a  chronically  distended  condition.  After 
labor  the  bruising  of  the  parts  caused  by  parturition  fre- 
quently make  spontaneous  micturition  impossible.  It  is 
generally  necessary  to  catheterize  the  patient  at  least  once 
after  labor,  and  often  repeatedly.  This,  however,  is  at- 
tended with  some  danger,  for  unless  strict  antiseptic  pre- 
cautions be  observed  the  catheter  may  become  contaminated 
with  lochial  discharge  and  the  bladder  may  be  infected. 
The  catheter  should  be  used  as  little  as  possible  for  this 
reason.  A  soft  rubber  catheter  is  preferable  and  this  should 
be  freshly  sterilized  before  use.  The  nurse  should  sterilize 
her  hands  and  wear  rubber  gloves. 

The  region  about  the  urethra  should  be  irrigated  with  an 
antiseptic  solution,  the  catheter  lubricated  with  sterile  gly- 
cerine or  oil,  and  introduced  with  the  aid  of  vision.  Gentle 
pressure  over  the  bladder  should  be  made  to  secure  its  thor- 
ough emptying. 

In  attempting  to  .secure  spontaneous  micturition  a  hot 


LACTATION 

turpentine  stupe  over  the  bladder,  and  the  pouring  of  warm 
fluid  over  the  external  parts  will  often  assist  greatly.  If 
necessary,  the  patient  may  be  raised  in  bed  for  this  purpose. 
The  blood  of  the  puerperal  woman  is  usually  normal  or 
shows  possibly  a  slight  anemia  as  lactation  develops.  Care 
should  be  taken  that  the  patient  does  not  become  anemic 
and  if  she  is  nursing  a  vigorous  child,  it  is  well  to  give  her  ar- 
senic and  iron  in  moderate  doses  during  the  puerperal  period. 

LACTATION 

A  correct  view  of  lactation  cannot  be  obtained  unless  it  be 
remembered  that  the  mammary  glands  are  not  sexual  organs, 
but  are  developed  from  tissue  analagous  to  the  sweat  glands 
of  the  skin.  The  development  of  successful  lactation  de- 
pends upon  the  absence  of  infection,  and  the  return  of  the 
mother  to  her  normal  physiological  condition.  Nervous 
disturbance  has  a  special  influence  in  preventing  lactation, 
as  nervous  disturbance  inhibits  the  action  of  the  secretory 
nerves.  The  development  and  filling  of  the  mammary  glands 
themselves  depend  largely  upon  the  temperament  of  the 
mother  and  her  general  condition. 

In  many  patients  the  breasts  at  labor  contain  a  thin  watery 
fluid  called  colostrum,  which  is  composed  largely  of  water, 
partially  formed  epithelial  cells  from  the  acini  of  the  breasts, 
and  the  extractive  matter.  This  fluid  acts  as  a  laxative  upon 
the  infant's  intestines.  The  formation  of  fully  developed 
breast  milk  depends  largely  upon  the  stimulation  of  nurs- 
ing, and  this  may  be  imitated  with  fair  success  by  the  use  of 
the  breast  pump  and  massage.  In  cases  where  for  some 
reason  the  child  cannot  nurse  for  some  time  after  birth,  the 
secretion  of  milk  may  still  be  retained  by  this  means.  Under 
the  stimulus  of  nursing  the  breasts  gradually  enlarge  until  at 
the  second  or  third  day  they  become  full  and  secrete  abund- 
antly. In  some  patients  milk  forms  very  suddenly  in  the 
breasts  with  what  is  described  as  a  rushing  feeling.  This 
may  cause  such  pressure  upon  the  nerves  of  the  breasts  as 
to  produce  great  reflex  disturbance  in  the  patient.  Consider- 
able rise  of  temperature,  rapid  pulse,  hysterical  manifesta- 
tions, profuse  perspiration,  swelling  of  the  lymphatic  glands 
in  the  axillae,  and  sometimes  in  the  neck,  are  observed.  The 


298  MANUAL    OF   OBSTETRICS 

fluid  first  drained  from  the  breast  is  excessively  yellow  and 
composed  almost  entirely  of  fat.  This  gives  place  upon  the 
third  or  fourth  day  to  the  normal  milk,  which  is  a  peculiar 
pearl-white  in  color.  While  the  early  secretion  is  very  rich 
and  fat,  the  normal  breast  milk  contains  from  4  to  6  per  cent, 
of  fat,  7  per  cent,  of  lactose  or  milk  sugar,  and  l^  to  2J/2  per 
cent,  of  proteid  matter.  In  healthy  patients  under  good  condi- 
tions no  pathogenic  bacteria  are  present  in  the  breast  milk; 
but  in  those  who  have  not  practised  cleanliness  during  preg- 


Fig.  112. — Primipara  in  the  puerperal  state,  with  normal  breasts  and 
successful  lactation. 

nancy  it  is  not  uncommon  to  find  staphylococci.  The  quan- 
tity secreted  varies  greatly  with  different  individuals  and 
can  only  be  estimated.  It  is  rarely  possible  to  obtain  by  the 
breast  pump  more  than  3  or  4  ounces  from  a  well  formed 
breast  which  is  secreting  freely.  The  child  is  undoubtedly 
more  successful,  and  by  weighing  the  child  before  and  after 
nursing  we  conclude  that  the  average  quantity  taken  from 
the  breast  at  each  nursing  is  between  4  and  5  ounces. 

The  secretion  of  breast  milk  may  be  naturally  increased  by 
causing  the  mother  to  drink  water  freely  and  to  take  milk 


LACTATION 


299 


and  milk  foods.  Next  in  importance  are  cereals,  among 
which  preparations  of  corn  are  especially  good;  and  next  in 
value  are  ripe  fruits  and  green  vegetables.  Large  quantities 
of  meat  are  not  only  not  useful,  but  harmful,  and  alcoholic 
drinks  and  strong  tea  and  coffee  are  objectionable.  It  is 
commonly  believed  that  coffee  lessens  the  secretion  of  milk 
and  that  tea  increases  it,  but  of  this  there  is  no  actual  proof. 
The  secretion  of  milk  may  usually  be  regulated  by  the  appe- 
tite of  the  child,  by  causing  the  child  to  nurse  the  breasts  al- 
ternately and  at  regular  hours.  During  the  first  twenty-four 
hours  after  birth  the  child  may  nurse  every  four  hours  by 
day,  and  not  disturb  the  mother  more  than  once  during  the 


Fig.  113. — Complete  aseptic  dressings  for  the  puerperal  state. 

eight  hours  by  night.  On  the  second  and  third  days  after 
birth,  three-hour  intervals  should  be  observed,  and  in  the 
average  child  three  hours  is  more  successful  than  more  fre- 
quent nursing. 

Nursing  should  be  governed  by  absolute  regularity.  If 
the  child  is  slow  in  thriving  it  may  be  nursed  more  fre- 
quently, every  two-and-a-half  hours.  If  the  mother  has  not 
all  that  is  required  for  the  child  she  need  not  be  disturbed 
at  night,  but  the  child  may  be  artificially  fed  once  during  the 
night. 

The  Care  of  the  Breasts  during  Lactation.— To  prevent 
engorgement  and  stasis  of  milk,  the  majority  of  patients  are 


300  MANUAL    OF   OBSTETRICS 

benefited  by  the  use  of  a  bandage  supporting  the  breasts 
smoothly  and  comfortably.  There  are  various  sorts  of 
bandages  applicable  for  this  purpose — the  breast-binder 
with  shoulder-straps,  the  double  sling  bandage,  and  others. 

The  nipples  should  be  kept  in  an  aseptic  condition  by 
cleansing  with  a  saturated  solution  of  boracic  acid  before  and 
after  the  child  nurses,  and  by  keeping  them  covered  with 
sterile  gauze  and  the  protecting  bandage.  The  tension  of 
the  bandage  may  be  varied  in  accordance  with  the  fullness  of 
the  breasts.  There  should  be  several  breast  bandages  avail- 
able, so  that  the  outer  bandage  can  be  frequently  washed. 

If  the  nipples  are  tender,  an  ointment  containing  10  grains 
of  powdered  boracic  acid  to  the  ounce,  will  be  found  a  use- 
ful application.  If  there  is  danger  that  the  nipples  may 
crack,  the  nipple  shield  should  be  used  during  nursing. 
Where  the  secretion  of  milk  is  established  with  difficulty 
and  the  breasts  are  very  tense,  gentle  massage  from  the  border 
of  the  breast  to  the  nipple,  with  warm  sterile  olive  oil,  will 
aid  greatly  in  promoting  the  patient's  comfort.  If  this  be 
followed  by  the  gentle  use  of  the  breast-pump,  the  tension 
will  be  relieved.  Massage  should  never  be  employed  if  it 
causes  pain,  and  hot  applications,  while  occasionally  useful, 
are  less  beneficial  than  massage. 

Where  the  nipple  is  inverted  it  should  be  drawn  out  by  the 
breast  pump  before  the  child  attempts  to  nurse.  The  pa- 
tient use  of  this  method  will  usually  enable  the  child  to  fi- 
nally draw  out  the  nipple. 

The  Complications  of  Lactation. — Where  the  nipples  crack 
and  bleed,  especial  care  must  be  taken  to  maintain  aseptic 
precautions.  The  nipple  shield  should  be  used  for  nursing, 
and  boracic  acid  solution  should  be  freely  applied  before  and 
after.  Where  the  cracks  are  obstinate  and  slow  in  healing, 
the  application  of  nitrate  of  silver  is  often  useful. 

Where  the  secretion  of  milk  is  deficient,  massage  and 
gentle  pumping  before  nursing  will  usually  increase  the  sup- 
ply. Where  the  secretion  is  excessive  and  rich  in  fat,  the  ap- 
plication of  the  breast  pump  before  the  child  nurses  will  re- 
move the  richest  of  the  milk  and  enable  the  child  to  take  the 
remainder.  Deficient  secretion  of  milk  calls  for  tonics  for 
the  mother  and  a  diet  rich  in  milk  and  milk  foods,  green  vege- 


LACTATION  301 

tables,  cereals,  and  cooked  fruit.  If  the  milk  is  thin  and  poor 
in  quality  a  moderate  quantity  of  fresh  beef,  chicken,  mut- 
ton, lamb,  squab  or  turkey,  should  be  added  to  the  diet. 
Fresh  eggs  are  also  useful  where  the  milk  is  poor  in  quality. 
The  abundant  use  of  water  is  necessary  in  promoting  a  proper 
secretion. 

Where  the  milk  is  excessive  in  quantity  and  rich  in  quality 
the  patient's  diet  should  be  restricted,  meat  should  be  omit- 
ted, and  no  excessive  quantity  of  fluid  taken.  The  use  of 
tea  or  coffee  may  depend  on  the  patient's  tastes. 

Should  the  breasts  become  hard  and  painful  all  manipula- 
tion which  causes  pain  should  be  carefully  avoided.  The 
breast  pump  should  be  used  very  gently  before  nursing,  and 
warm  applications  with  the  bandage  are  often  useful.  Should 
an  area  which  is  red  and  tender  develop,  with  some  rise  in  the 
patient's  pulse  and  temperature,  infection  has  occurred. 
When  this  develops  the  child  should  not  nurse  from  that 
breast,  the  breasts  should  be  supported  by  a  bandage,  and  a 
dry  ice  bag  placed  over  the  reddened  area.  The  patient 
should  be  given  a  saline  laxative.  If  the  infection  does  not 
spread,  but  subsides,  the  redness  will  disappear  and  the  ten- 
derness will  gradually  subside.  If  the  infection  goes  on  to 
the  formation  of  pus,  the  patient's  pulse  and  temperature 
will  indicate  infection,  there  will  be  bogginess  on  pressure  over 
the  infected  area,  the  skin  will  be  red  and  somewhat  tender, 
and  on  examining  the  blood  there  may  be  increased  leuko- 
cytosis. 

Treatment  of  Breast  Abscess. — When  a  collection  of  pus 
is  present,  incision  and  drainage  are  indicated.  The  incision 
should  always  be  made  parallel  with  the  milk  ducts  and  not 
transversely  to  their  course.  If  but  one  reddened  area  has 
developed  and  there  is  slight  disturbance  of  pulse  and  tem- 
perature, that  area  only  should  be  incised.  The  pus  should 
be  freely  evacuated,  the  cavity  cleansed  with  peroxide  of  hy- 
drogen or  1  per  cent,  lysol,  and  drained  with  iodoform  gauze. 
Daily  dressings  and  irrigation  should  be  practised  until  the 
area  has  closed  by  granulation.  Should  infection  be  ex- 
tensive in  the  breasts  simple  incision  will  not  suffice.  The 
patient  must  be  anesthetized,  the  breasts  thoroughly  cleansed, 
and  the  point  where  the  most  fluctuation  is  obtained  should 


302  MANUAL   OF   OBSTETRICS 

be  first  opened  sufficiently  to  admit  the  gloved  finger.  The 
finger  should  then  be  carried  in  different  directions  in  the 
breast,  and  if  multiple  infection  be  present  the  infected  areas 
will  break  down  under  the  pressure  of  the  finger.  With 
blunt-pointed  forceps  two  good-sized  rubber  drainage  tubes 
should  then  be  drawn  through  the  breasts  obliquely  from 
above  downward.  These  drainage  tubes  should  cross  near 
the  nipple.  The  tubes  should  be  washed  with  an  antiseptic 
solution  forced  through  them  by  a  piston  syringe,  and  the 
breasts  covered  with  a  copious  dressing  of  antiseptic  gauze. 
Daily  irrigation  and  dressing  are  required,  with  the  gradual 
withdrawal  of  the  tubes,  until  the  infection  has  entirely  sub- 
sided. In  severe  and  neglected  cases,  where  the  breast  has 
become  thoroughly  riddled  with  infection,  it  may  be  neces- 
sary to  remove  the  entire  organ. 

It  is  rarely  possible  for  the  child  to  nurse  from  the  other 
breast  if  one  is  severely  infected.  If,  however,  the  sound 
breast  remains  healthy  an  effort  may  be  made  to  continue 
the  nursing,  taking  all  precautions  to  avoid  the  spread  of  in- 
fection. It  is  usually  safer,  however,  to  abandon  lactation 
if  severe  infection  develops. 

The  Treatment  of  the  Breasts  after  the  Death  of  the  In- 
fant.— When  the  death  of  the  infant  takes  away  the  natural 
consumption  of  the  milk,  the  breasts  must  be  thoroughly 
cleansed  with  an  antiseptic  solution,  covered  with  a  thin 
layer  of  cotton,  and  firmly  but  smoothly  bandaged.  If  there 
is  much  pain  lead  water  and  laudanum  may  be  applied  upon 
sterile  surgeons  lint.  The  breasts  should  not  be  disturbed 
by  pumping  or  massage,  the  patient  should  be  given  an  effi- 
cient saline  purgative,  and  her  diet  lessened,  and  especially 
the  amount  of  liquids  taken.  Under  this  treatment  the  se- 
cretion of  milk  will  speedily  subside  without  difficulty. 


CHAPTER  XVI 

THE  CARE  OF  THE  NORMAL  INFANT  DURING  THE 
MOTHER'S  PUERPERAL  PERIOD 

During  the  mother's  puerperal  period  the  care  of  the 
infant  should  be  conducted  with  regularity,  and  it  should  be 
carefully  guarded  from  disturbance.  Whenever  possible  the 
child  should  not  remain  in  the  room  with  the  mother,  but  in 
a  room  sufficiently  removed,  so  that  its  crying  will  not  dis- 
turb the  mother.  A  warm,  well  ventilated  room  is  desirable, 
with  exposure  to  sunlight,  and  one  free  from  dampness. 

Soon  after  birth  the  child  should  be  thoroughly  rubbed 
with  sterile  olive  oil,  and  after  the  mother  has  received  atten- 
tion, if  the  child  is  breathing  well,  it  may  be  given  its  first 
bath.  The  use  of  separate  sponges  or  wash  cloths  for  the 
head  and  face  and  the  remainder  of  the  body,  is  indicated. 
In  the  presence  of  epidemic  disease,  pointing  to  a  contami- 
nated water  supply,  the  water  used  in  bathing  the  child  should 
have  been  sterilized  by  boiling.  Care  must  be  taken  that 
during  the  bath  the  child  does  not  become  chilled,  and  if 
possible  the  child  should  be  before  an  open  fire  while  the 
nurse  is  surrounded  by  a  screen.  If  the  child  is  feeble  or 
breathes  badly,  the  bath  should  be  omitted  until  it  rallies. 

Except  in  hot  weather,  wool  is  the  best  material  for  the 
child's  clothing  next  the  skin. 

The  stump  of  the  umbilical  cord  should  be  carefully  in- 
spected to  see  that  the  ligature  is  holding  and  that  there  is 
no  bleeding.  The  cord  may  be  dusted  with  sterile  powder 
consisting  of  powdered  starch,  with  one  part  of  boracic  or 
salicylic  acid  to  ten  of  starch.  This  may  be  sterilized  by 
baking  in  an  oven.  The  cord  should  be  dressed  with  sterile 
cotton  and  the  dressing  maintained  in  position  with  an  ab- 
dominal bandage  of  thin  woolen  material.  During  the  first 
bath  the  child  should  be  carefully  inspected  to  see  that  no 
abnormalities  are  present  and  that  there  is  no  obstacle  to 

303 


304 

the  discharge  of  urine  and  feces.  It  should  be  given  boiled 
water  as  soon  as  possible. 

If  the  child  is  fretful  and  restless  the  large  intestine  should 
be  thoroughly  irrigated  with  equal  parts  of  sterile  salt  solution 
and  boiled  water.  For  the  first  twenty-four  hours  after  birth 
the  child  requires  no  food,  but  should  have  water  in  small 
quantities  abundantly.  So  soon  as  the  mother  is  rested  the 
child  should  be  put  to  the  breast,  and  every  four  hours  after 
that,  omitting  the  night. 

If  the  meconium  comes  away  tardily,  castor  oil  followed 
by  irrigation  is  indicated. 

The  child's  nursery  should  be  well  aired  at  all  times,  and 
exposed  to  the  sun  in  all  but  the  hottest  weather.  If  abso- 
lute regularity  be  observed  in  the  care  of  the  infant,  and  it 
is  not  allowed  to  be  picked  up  and  handled  indiscriminately 
the  child  will  usually  develop  without  difficulty. 

Should  the  mother's  milk  be  slow  in  forming  the  infant 
may  be  fed  upon  modified  cow's  milk  or  partially  digested 
milk  or  condensed  milk.  Where  milk  does  not  seem  to  agree, 
white  of  egg  water  may  be  given,  sweetened  with  milk  sugar. 
If  the  mother  can  ill  endure  the  disturbance  of  night  nursing 
and  the  condition  of  the  breasts  permits,  the  child  should  be 
fed  artificially  once  or  twice  during  the  night,  allowing  the 
mother  to  remain  undisturbed.  The  frequency  of  nursing 
should  rarely  exceed  three  hours,  from  six  or  seven  o'clock  in 
the  morning  until  ten  or  eleven  o'clock  at  night. 

The  Protection  of  the  Infant  from  Infection. — The  infant 
may  become  infected  in  the  mouth,  the  nose,  the  stump  of 
the  umbilical  cord,  and  the  intestine.  Where  influenza  is 
prevalent  this  germ  may  gain  access  to  the  child's  nose  and 
throat.  Occasionally  the  streptococcus  and  the  diphtheria 
bacillus  attack  infants.  There  is  no  adequate  method  of  pro- 
tecting infants  from  such  infection,  except  to  keep  from  them 
those  persons  who  are  known  to  be  infected. 

If  the  child's  mouth  be  not  cleansed  from  infected  material 
some  of  the  lower  forms  of  bacteria  may  grow  luxuriantly 
in  the  mouth,  forming  whitish  patches  known  as  thrush. 
The  gonococcus  may  also  infect  the  child's  mouth,  producing 
characteristic  lesions,  so  the  mouth  may  also  be  the  site  of 
syphilitic  infection. 


NORMAL    INFANT  DURING    PUERPERUM  305 

To  avoid  infection  great  care  should  be  taken  that  the 
child's  mouth  bo  cleansed  with  the  least  possible  violence 
and  disturbance.  Small  pieces  of  old,  soft  linen,  ster- 
ilized by  boiling,  should  be  used  to  cover  the  finger,  and 
this  should  be  dipped  in  a  saturated  solution  of  boracic  acid. 
When  infection  develops,  material  from  the  infected  area 
should  be  taken  for  bacteriological  examination — when  a 
correct  diagnosis  may  be  made.  If  diphtheria  be  present 
antitoxin  must  be  given;  and  if  mixed  infection  has  developed 
vaccines  may  be  used.  The  infected  mouth  of  the  child 
may  in  turn  infect  the  mother's  breast,  if  there  be  cracks  or 
fissures  in  the  nipple.  The  child  may  swallow  the  infected 
secretions  from  ulcerating  surfaces,  and  enteritis  may  be  the 
consequence.  In  these  cases  attention  must  be  given  to  the 
state  of  the  mouth  and  the  child's  intestines  should  be  thor- 
oughly irrigated,  so  far  as  possible,  with  boiled  water  and 
sterile  salt  solution.  If  feeding  be  artificial  the  milk  which 
the  child  takes  should  be  pasteurized. 

Infections  in  the  Umbilical  Region. — The  tissues  about  the 
stump  of  umbilical  cord  or  the  stump  itself  may  become  in- 
fected from  infected  dressings  or  hands.  In  these  cases 
there  is  redness  and  swelling  about  the  umbilicus.  Where 
infection  is  severe  the  child  soon  shows  the  effects  by  dis- 
turbance of  pulse  and  temperature.  Umbilical  infection 
frequently  becomes  a  blood  infection,  when  the  child  will 
have  great  disturbance  of  pulse  and  temperature  and  the 
signs  of  a  septic  condition  in  the  blood.  Should  the  umbili- 
cus become  infected  and  pus  form  in  the  subcutaneous  tissue, 
it  should  be  evacuated  by  incision,  and  boracic  acid  or  salt 
solution  applied  on  gauze  compresses. 

In  addition  to  its  milk  the  child  should  take  whiskey  or 
brandy,  well  diluted. 

Intestinal  Infections  in  the  Infant. — If  the  breast  milk  be 
infected  and  the  child  nurses,  staphylococci  and  other  germs 
may  be  found  in  the  child's  fecal  discharges.  Boiled  water 
should  be  used  exclusively  for  the  child's  drinking,  and  any- 
thing which  enters  the  child's  mouth  should  be  sterile  be- 
fore it  is  used.  The  child's  intestinal  discharges  may  carry 
infection,  and  its  diapers  should  be  rinsed  in  antiseptic  solu- 
tions and  boiled  before  they  are  used  again. 


306  MANUAL   OF   OBSTETRICS 

So  far  as  the  direct  treatment  of  intestinal  infection  in  in- 
fants is  concerned,  copious  and  gentle  irrigation  of  the  large 
bowel  with  boiled  water  and  salt  solution,  is  our  best  method 
of  treatment.  If  the  infection  be  severe  a  fatal  result  may 
follow. 

The  Care  of  the  Eyes  in  the  Infant. — At  the  moment  of 
birth  a  drop  of  argyrol,  from  10  to  20  per  cent.,  should  be 
dropped  into  each  eye,  and  the  eye  flushed  with  boiled  water 
or  boracic  solution.  Care  should  be  taken  that  the  child's 
nails  are  trimmed  and  that  it  does  not  wound  the  eye  by 
inserting  the  fingers.  A  bright  light  should  be  avoided  and 
also  exposure  to  cold,  and  severe  winds. 

Should  redness  and  swelling  with  a  muco-purulent  dis- 
charge appear  in  the  eyes  the  physician  should  be  at  once 
notified,  and  cultures  be  taken  for  diagnosis. 


CHAPTER  XVII 
OBSTETRIC  ASEPSIS  AND  ANTISEPSIS 

So  important  is  this  subject  in  obstetric  practice  that  espe- 
cial attention  is  demanded. 

THE  PATIENT'S  BIRTH  CANAL 

Infective  bacteria  have  been  repeatedly  found  in  the  vagina 
of  a  perfectly  healthy  patient.  Such  bacteria  do  not  gain 
access  to  the  lymphatics  or  blood  vessels  under  normal  con- 
ditions, because  the  parts  are  protected  by  an  acid  mucous 
secretion  which  is  germicidal.  If  repeated  examinations 
wound  the  mucous  membrane  bacteria  may  gain  access 
through  these  wounds.  Under  normal  conditions  vaginal 
douching  is  unnecessary  and  dangerous,  because  it  removes 
the  natural  protection  of  the  tissues  and  subjects  the  patient 
to  the  risk  of  wounds  and  lacerations.  Where,  however, 
labor  is  prolonged,  the  amniotic  liquid  has  been  lost  and  air 
has  entered  the  vagina,  repeated  examinations  and  manipu- 
lations have  been  made,  the  natural  protection  of  the  tissues 
has  been  disturbed,  and  the  condition  is  pathological. 

Under  these  circumstances,  before  delivery  the  vagina 
should  be  thoroughly  irrigated  with  warm  lysol  mixture,  1 
per  cent. 

While  every  effort  should  be  made  to  allow  the  internal 
genital  organs  to  escape  contamination  the  external  parts  and 
the  skin  surrounding  them  should  be  cleansed  by  sterile 
water  and  soap,  followed  by  sterile  hot  water  and  by  an  anti- 
septic solution.  The  hair  should  be  trimmed  closely  or 
shaven.  During  labor  sterile  vulvar  dressings  should  be 
worn  and  maintained  in  position  by  a  T-bandage. 

Care  must  be  taken  that  the  patient's  birth  canal  does 
not  become  infected  during  preparations  for  labor.  The  tub- 
bath  should  give  place  to  the  shower  bath,  or  that  obtained 
by  having  the  patient  stand  in  a  bath-tub  while  the  nurse 

307 


308  MANUAL   OF   OBSTETRICS 

pours  warm  water  over  her  from  a  pitcher.  Care  should 
be  taken  to  use  cleanliness  after  defecation  to  prevent  germs 
from  the  intestine  entering  the  vagina. 

During  prolonged  labor,  with  frequent  examinations  and 
manipulations,  gentle  irrigation  with  warm  lysol,  1  per  cent., 
should  precede  these  procedures.  The  use  of  sterile  rubber 
gloves  greatly  lessens  the  danger  of  vaginal  infection.  Instru- 
ments and  appliances  introduced  within  the  vagina  must  be 
surgically  sterile.  After  labor  but  one  copious  vaginal  irri- 
gation should  be  used,  but  none  is  needed  during  the  puer- 
peral period. 

The  Uterus. — The  uterine  cavity  should  not  be  entered  by 
hand  nor  instrument  without  definite  indications.  Uterine 
manipulation  must  be  preceded  by  copious  gentle  irrigation 
of  the  vagina  with  lysol  1  per  cent.  The  use  of  sterile  rubber 
gloves  should  be  invariable  for  intrauterine  manipulations. 
The  exercise  of  gentleness  and  caution  to  avoid  wounding  the 
endometrium  is  also  necessary. 

In  delivery,  tears  of  the  cervix  should  be  avoided  so  far 
as  possible,  as  they  are  open  doors  for  the  entrance  of  infec- 
tion. If  during  labor  intrauterine  manipulation  has  been 
practised,  or  if  the  placenta  has  been  removed  by  the  intro- 
duction of  the  hand,  the  uterus  should  be  very  thoroughly 
irrigated  after  labor  with  lysol  1  per  cent.,  or  sterile  salt  solu- 
tion, and  tamponed  with  10  per  cent,  iodoform  gauze.  This 
may  be  allowed  to  remain  forty-eight  hours  and  then  re- 
moved, and  a  second  irrigation  with  lysol  given.  No  more 
intrauterine  manipulation  should  be  practised.  The  im- 
mediate closure  of  extensive  lacerations  of  the  cervix  uteri 
complicating  labor  is  of  direct  advantage  in  preventing  the 
development  of  infection. 

Of  equal  importance  with  antiseptic  precautions  is  the 
securing  of  firm  contraction  of  the  uterine  muscle  after  labor. 
Tonic  doses  of  strychnia  and  ergot  have  direct  value  in  pre- 
venting septic  infection.  It  is  also  important  that  after 
the  uterus  has  been  emptied  it  should  be  left  in  normal  posi- 
tion. If  the  puerperal  uterus  is  relaxed  and  retro  verted 
the  lochial  discharge  will  accumulate  and  infection  develop. 

In  the  conduct  of  delivery  through  the  vagina,  and  especially 
hi  the  third  stage  of  labor,  care  should  be  taken  not  to  carry 


THE  PATIENT'S  BIRTH  CANAL  309 

germs  from  the  vagina  into  the  cervix  and  into  the  uterine 
cavity.  While  it  is  theoretically  impossible  that  any  labor 
should  be  absolutely  without  the  presence  of  germs,  still  with 
care  one  may  prevent  infection  and  secure  the  proper  dis- 
charge of  the  lochia  and  the  contraction  of  the  uterus. 

The  External  Skin. — Many  obstetric  cases  must  be  de- 
livered by  section  and  there  are  emergencies  where  but  little 
time  is  available  for  elaborate  preparation. 

In  preparing  the  skin  for  incision  one  must  remember 
the  action  of  the  various  antiseptics  commonly  used.  Bi- 
chloride of  mercury,  lysol  and  alcohol  act  best  upon  a  wet 
skin.  Iodine  is  efficient  upon  a  dry  skin. 

For  emergency  preparation  of  the  abdomen  the  skin  should 
be  scrubbed  as  thoroughly  as  possible  with  sterile  gauze 
and  tincture  of  green  soap. 

Especial  attention  should  be  given  to  the  umbilicus.  The 
hair  above  the  pubes  should  be  shaved  or  cut  close.  The  ex- 
ternal cleansing  should  extend  down  upon  the  thighs  and 
upwards  to  beneath  the  breasts.  The  scrubbing  with  soap 
should  be  followed  by  the  plentiful  use  of  hot  sterile  water 
and  this  by  hot  bichloride  of  mercury  solution,  1 : 2000,  or 
lysol  1  per  cent.,  or  pure  alcohol  95  per  cent.  If  there  is  to 
be  a  slight  delay  after  preparation  a  copious  dressing  of  sterile 
gauze  should  be  bandaged  upon  the  abdomen.  Just  before 
incision  tincture  of  iodine  may  be  applied  upon  sterile  gauze. 

Where  ample  time  is  given  for  preparation,  this  prepara- 
tion should  be  done  on  the  evening  preceding  the  operation, 
on  the  following  morning,  and  the  iodine  applied  just  before 
incision. 

As  has  been  stated,  the  vaginal  preparation  for  operation 
should  consist  of  copious  but  gentle  irrigation  with  1  per 
cent,  lysol.  We  have  had  good  results  by  irrigation  with 
equal  parts  of  1  per  cent,  lysol  and  tincture  of  green  soap. 

The  Aseptic  Care  of  the  Breasts. — This  division  of  the 
subject  of  asepsis  and  antisepsis  has  been  discussed  in  the 
management  of  the  puerperal  state. 

In  caring  for  the  nipples  it  must  be  remembered  that  the 
epithelia  upon  them  is  easily  wounded  and  that  methods  of 
cleansing  and  applying  antiseptics  must  be  selected  with 
that  knowledge  in  mind. 


310  MANUAL   OF   OBSTETRICS 

In  preparing  the  skin  surface  of  the  breasts  and  the  sur- 
rounding tissues  for  operation,  the  method  described  in 
preparing  the  skin  of  the  abdomen  may  be  employed,  omit- 
ting the  application  of  iodine. 

The  Aseptic  Care  of  Wounds  and  Lacerations  Accompany- 
ing Delivery. — Abdominal  wounds  accompanying  delivery 
should  receive  the  same  antiseptic  and  aseptic  treatment 
indicated  in  other  cases.  As  the  abdominal  incision  is  often 
a  long  one,  and  the  tissues  are  relaxed  and  stretched,  especial 
care  must  be  taken  to  hold  abdominal  dressings  firmly  in 
place  and  to  support  the  entire  incision.  For  this  purpose 
broad  strips  of  adhesive  plaster  fastened  two-thirds  of  the 
way  around  the  patient's  body,  and  overlapping,  make  the 
most  efficient  dressing.  Abdominal  wounds  should  be  left 
thoroughly  dry  and  clean  and  covered  by  sterile  gauze,  and 
should  be  disturbed  as  little  as  possible  during  the  healing 
process.  If  dressings  become  stained  by  oozing  they  must 
be  renewed.  Stitches  should  be  retained  as  long  as  possible, 
in  view  of  the  length  of  the  incision  and  the  character  of  the 
tissues.  An  accurately  fitting  belt  is  necessary  to  support 
the  abdomen  during  the  latter  portion  of  convalescence. 

The  Antiseptic  Care  of  Lacerations  in  the  Birth  Canal. — 
Where  lacerations  of  the  cervix,  anterior  and  posterior  seg- 
ments of  the  pelvic  floor  and  perineum,  occur,  such  lacera- 
tions should  be  repaired  as  soon  as  possible  under  antiseptic 
precautions.  If  the  uterus  has  been  tamponed  in  these 
cases  the  vagina  should  be  cleansed  with  an  antiseptic  solu- 
tion and  a  vaginal  packing  of  bichloride  or  sterile  gauze 
should  be  inserted  after  operation.  Stitches  in  the  anterior 
and  posterior  segments  of  the  pelvic  floor  and  the  perineum 
must  be  cleansed  by  pouring,  from  a  pitcher  or  other  suitable 
vessel,  a  warm  lysol  mixture  of  1  per  cent.,  sterile  salt  solution 
or  boracic  acid,  or  bichloride  solution  1 : 4000.  This  should  be 
done  whenever  the  bowels  or  bladder  are  emptied,  or  when- 
ever the  vulvar  dressing  is  stained  through  with  discharge. 
It  is  unnecessary  to  introduce  a  tube  within  the  vagina  and 
lacerated  surfaces  should  not  be  touched.  Copious  vulvar 
dressings  of  sterile  or  bichloride  gauze  with  a  T-bandage  are 
required. 


THE  PATIENT'S  BIRTH  CANAL  311 

The  Prevention  of  Infection  during  the  Use  of  the  Cath- 
eter or  Rectal  Tube. — It  is  of  especial  importance  during 
this  common  manipulation  that  infection  should  not  occur. 
Before  the  use  of  the  catheter  the  parts  should  be  thoroughly 
cleansed  with  sterile  water,  and  then  with  bichloride  1 : 4000, 
or  lysol  1  per  cent.  A  sterile  catheter,  lubricated  with  sterile 
glycerine  or  sterile  oil,  should  be  taken  in  the  gloved  hand, 
the  orifice  of  the  urethra  sponged  with  cotton  dipped  in 
bichloride  solution,  and  the  catheter  gently  introduced. 
Precautions  should  be  taken  that  the  urine  does  not  soil  the 
tissues.  When  the  catheter  is  to  be  removed  the  thumb  or 
finger  should  be  placed  over  the  distal  end,  and  cotton  soaked 
in  bichloride  solution  should  be  used  in  sponging  the  tissues 
about  the  urethra.  After  catheterizing  an  antiseptic  solu- 
tion should  be  poured  over  the  tissues  about  the  urethra. 

In  using  the  rectal  tube  there  is  danger  that  the  contents 
of  the  bowel  containing  the  bacillus  coli  communis  may 
contaminate  the  wounds  and  lacerations  in  the  perineum 
and  pelvic  floor.  To  prevent  this  the  vulva  should  be  cov- 
ered with  gauze  during  intestinal  irrigation,  or  the  giving 
of  enemata. 

Salt  solution  may  be  employed  with  advantage  for  irriga- 
tion, and  the  return  flow  should  be  guarded  to  prevent  con- 
tamination of  perineal  and  vaginal  tissues.  Should  stitches 
in  the  perineum  or  pelvic  floor  become  infected  they  should 
at  once  be  removed  and  the  surfaces  very  thoroughly  flushed 
with  lysol  1  per  cent. 

Pregnant  patients  sometimes  suffer  from  hemorrhoids 
and  from  fissures  in  the  mucous  membrane  of  the  bowel. 
These  regions  are  best  guarded  from  infection  by  the  use  of  a 
sterile  ointment  for  hemorrhoids,  by  irrigation  of  the  intestine 
with  salt  solution,  and  by  the  application  of  nitrate  of  silver. 

The  general  principles  of  asepsis  and  antisepsis  as  applied  to 
the  puerperal  period  require  that  the  puerperal  patient  should 
be  aseptically  dressed,  like  a  surgical  patient.  The  breasts 
and  the  vulva  require  occlusion  dressings,  while  the  abdomen 
needs  a  splint  or  supporting  dressing  to  maintain  the  uterus 
in  its  proper  position  and  contraction.  The  overdistended 
abdominal  muscles  require  constant  support  until  they  have 
regained,  at  least  hi  some  degree,  their  normal  tone. 


312  MANUAL   OF   OBSTETRICS 

THE  ASEPTIC  AND  ANTISEPTIC  PREPARATION  OF  THE 
HANDS  OF  DOCTOR  AND  NURSE 

The  practical  application  of  antisepsis  to  the  hands  of  doc- 
tor and  nurse  is  necessary,  both  in  the  interests  of  the  patient 
and  her  attendant.  For  the  patient  it  removes  a  frequent 
and  most  important  cause  of  septic  infection,  while  it  pro- 
tects the  doctor  and  nurse  from  specific  or  septic  infection 
acquired  from  the  patient. 

The  Hygienic  Care  of  the  Hands. — As  a  matter  of  pre- 
caution doctors  and  nurses  need  to  keep  the  hands  in  the 
best  possible  condition.  Chapped  and  abraded  surfaces  on 
the  skin  should  be  thoroughly  cleansed  with  soap  and  water, 
and  alcohol  applied  as  an  antiseptic  or  a  healing  ointment. 
The  nails  should  be  kept  short  and  trimmed  whenever  they 
become  rough  and  projecting.  "  Hang-nails ' '  are  exceedingly 
dangerous  to  those  engaged  in  obstetric  practice,  for  the  skin 
usually  becomes  abraded  or  wounded  at  that  point,  and  sep- 
tic infection  can  gain  access.  Orange  wood  sticks  should  be 
used  for  cleaning  the  nails  and  for  pushing  the  skin  back  at 
the  face  of  the  nails.  Sharp-pointed,  slender  scissors,  curved 
on  the  back,  are  needed,  and  a  nail-file  to  keep  the  nails  per- 
fectly smooth.  Nail  brushes  should  not  be  soft  nor  exces- 
sively hard  and  those  of  good  quality  are  most  efficient  and 
economical  for  constant  use.  Unirritating  soap  should  be 
employed,  as  castile,  and  scented  soaps  are  usually  inefficient 
and  undesirable.  Tincture  of  green  soap,  where  it  agrees 
with  the  skin,  is  an  especially  valuable  preparation. 

The  Preparation  of  the  Hands  for  Actual  Attendance  in 
Labor. — Two  methods  of  preparing  the  hands  are  in  common 
use  at  the  present  time.  In  one  the  antiseptic  selected  is 
bichloride  of  mercury,  in  the  other  lysol.  Bichloride  of 
mercury  has  the  advantage  of  being  odorless,  readily  carried 
in  tablets,  and,  if  properly  used,  efficient.  Lysol  is  a  liquid, 
has  an  odor  to  which  some  patients  object,  but  is  useful  as  an 
antiseptic  and  lubricant.  It  is  usually  less  severe  in  its  action 
upon  the  skin  than  bichloride  of  mercury.  These  two  anti- 
septics have  a  further  and  very  important  influence — that 
bichloride  of  mercury  is  rendered  inert  by  soap,  while  lysol 
combines  readily  with  soap. 

If  bichloride  of  mercury  be  selected  the  hands  should  first 


PREPARATION    OF    HANDS  313 

be  cleansed  in  hot  sterile  water  with  a  reliable  soap  and  with 
a  nail  brush,  the  hands  and  forearms  being  thoroughly 
scrubbed  above  the  elbows.  It  is  not  the  length  of  time  em- 
ployed in  scrubbing,  but  the  thoroughness  and  vigor  of  the 
scrubbing  which  is  efficient.  Following  this  scrubbing  the 
hands  and  forearms  should  be  again  scrubbed  or  rubbed  thor- 
oughly with  gauze  and  with  sterile  hot  water  so  that  the  soap 
is  removed.  While  the  hands  and  arms  are  still  wet  they 
should  be  placed  in  1 : 2000  bichloride  of  mercury  solution, 
and  brushed  or  rubbed  with  gauze  until  all  parts  have  been 
thoroughly  gone  over.  The  hands  and  forearms  may  then  be 
dried  by  a  sterile  towel  and  sterile  rubber  gloves  placed  upon 
the  hands.  The  forearms  should  be  covered  by  a  sterile 
gown  which  comes  to  the  wrists,  the  gloves  being  pulled  up 
over  the  sleeves  of  the  gown. 

During  labor  the  gloved  hands  should  be  repeatedly  rinsed 
in  bichloride  solution  and  thus  kept  in  a  practically  sterile 
condition. 

If  lysol  be  used  the  hands  and  arms  should  be  scrubbed 
with  soap  and  water,  as  in  the  first  instance,  thoroughly 
cleaned  in  sterile  water,  and  then  with  1  per  cent,  lysol.  The 
gloved  hand  dipped  in  lysol  is  lubricated  sufficiently  for  vag- 
inal examinations  and  operations. 

The  Use  of  the  Gloves. — While  a  careful  obstetrician  with 
sound  hands  can  conduct  labors  successfully  without  the 
use  of  gloves,  the  risk  to  the  patient  and  to  himself  is  greater 
than  if  gloves  are  employed.  It  is  true  that  the  gloved  hand 
has  a  less  secure  grasp  upon  the  newborn  child  covered  with 
vernix  caseosa,  but  with  practice  this  objection  can  be  over- 
come, and  if  the  child  be  grasped  with  sterile  gauze  in  the 
hand  the  difficulty  disappears.  In  prolonged  operations  the 
rubber  glove  may  loosen  the  epithelia  upon  the  hands  and 
set  free  bacteria  and  spores  in  the  deeper  layers.  There 
seems  to  be  no  practical  way  of  avoiding  this  difficulty,  un- 
less possibly  the  use  of  the  gloves  wet  in  bichloride  solution 
lessens  this  danger.  If  the  glove  becomes  torn  or  perforated 
during  an  operation,  blood  or  secretions  from  the  birth  canal 
may  be  retained  within  the  torn  glove  and  be  a  source  of  some 
danger.  With  practice  the  glove  should  not  obscure  the 
sense  of  touch  for  diagnostic  purposes.  The  thinnest  and 


314  MANUAL   OF   OBSTETRICS 

best  quality  of  gloves  should  be  selected,  and  the  gloves  should 
not  be  so  large  as  to  wrinkle  upon  the  hand.  The  best  gloves 
bear  repeated  boiling,  and  when  sterilized  should  be  dried 
and  dusted  with  aseptic  powder. 

The  Hands  in  Septic  Cases. — In  dealing  with  septic  cases 
suspected  of  specific  taint,  especial  care  must  be  taken  that 
the  gloves  are  sound  and  that  no  puncture  or  tear  of  the 
glove  occurs.  Gloves  employed  for  these  cases  when  not  in 
use  should  be  kept  in  a  solution  of  bichloride  or  lysol.  When 
the  case  is  terminated  gloves  used  about  the  patient  should 
be  burned. 

The  Treatment  of  Wounds  or  Abrasions  upon  the  Hands.— 
A  slight  aseptic  wound  or  abrasion  should  be  protected  by 
collodion  or  an  antiseptic  dressing,  and  in  the  event  of  labor 
occurring  especial  care  must  be  taken  in  rendering  the  hands 
aseptic,  and  in  the  use  of  gloves.  With  these  precautions 
a  slight  wound  or  abrasion  which  shows  no  sign  of  infection 
is  practically  not  dangerous  to  the  parturient  woman.  Such 
an  injury  is  dangerous,  however,  to  the  person  whose  hand  is 
involved,  and  if  the  case  is  a  suspicious  one  it  should  be,  if 
possible,  turned  over  to  someone  else.  If,  however,  this 
cannot  be  done  every  precaution  should  be  taken  to  protect 
the  hand  by  gloves. 

INSTRUMENTS  AND  APPLIANCES 

Nickel-plated  instruments  are  readily  kept  in  good  condi- 
tion by  sterilizing  them  by  boiling  in  1  per  cent,  lysol.  Al- 
though few  forceps  with  rubber  handles  are  now  used,  if 
such  have  been  made  in  the  best  possible  manner  the  rubber 
handles  will  endure  repeated  boiling  in  lysol.  In  cleaning 
craniotomy  instruments  or  forceps  having  complicated  locks, 
especial  care  must  be  taken  to  clean  screw-threads  or  any 
other  portion  of  the  instrument  where  blood  or  secretions 
from  the  birth  canal  might  lodge.  A  hot  solution  of  bicar- 
bonate of  soda  and  a  brush  are  often  useful.  Obstetric 
instruments  should  be  kept  in  good  condition  and  perfectly 
plated  with  nickel,  or  roughened  surfaces  may  wound  the 
birth  canal  of  the  mother  during  delivery. 

Glass  tubes  employed  for  irrigation,  suture  material,  and 
dilating  bags,  may  be  sterilized  by  boiling  or  under  pressure 


INSTRUMENTS    AND    APPLIANCES  315 

of  heated  steam.  Boiling  is  unquestionably  the  most  prac- 
tical and  efficient  method.  If  silk  be  employed  to  ligate  the 
umbilical  cord  it  should  be  of  good  size  and  thoroughly  boiled 
and  soaked  in  alcohol  before  use.  Catgut  in  tubes  may  be 
heated  by  boiling  the  tubes  before  use.  Silkworm  gut  is 
readily  sterilized  by  boiling. 

The  obstetrician  may  prefer  to  sterilize  instruments  and 
appliances  at  the  time  when  they  are  used  or  to  sterilize  them 
at  his  convenience  in  his  office,  wrap  with  sterile  material, 
and  to  take  them  in  a  sterile  condition  to  the  house  of  the 
patient.  While  the  latter  method  is  often  convenient,  it 
has  the  disadvantage  that  in  a  long-continued  labor  it  may 
be  necessary  to  use  an  instrument  or  appliance  several  times. 
Obviously  on  each  occasion  sterilization  is  necessary,  and  if 
the  obstetrician  has  not  the  appliances  at  hand  for  accom- 
plishing this  he  must  improvise  a  sterilizer  with  domestic 
utensils. 

If  the  obstetrician  carries  a  sterilizer  with  him  he  can  read- 
ily sterilize  his  instruments  and  appliances  as  often  as  neces- 
sary, and  he  has  the  advantage  of  having  them  in  sterilized 
receptacles  at  the  time  of  delivery.  Personally,  we  have 
found  it  convenient  to  use  a  nickel-plated  or  copper  double 
box,  one  portion  fitting  over  the  other,  in  which  instruments 
and  appliances  may  be  carried.  Two  alcohol  lamps  and 
stands  accompany  the  sterilizer.  For  use,  the  alcohol  lamps 
and  stands  are  placed  in  the  bottom  of  an  empty  bathtub, 
and  instruments,  sutures  and  appliances  prepared  for  use 
are  boiled  in  the  sterilizer  with  1  per  cent,  lysol  for  half  an 
hour.  The  upper  portion  of  the  box  is  placed  over  the  lower 
so  that  the  steam  which  forms  is  utilized.  This  box  remains 
closed  until  delivery,  when  the  upper  empty  half  may  be 
used  for  suture  and  ligature  materials,  thus  avoiding  con- 
fusion with  other  instruments.  If  the  lysol  solution  in  which 
the  instruments  were  boiled  is  allowed  to  remain  and  to  cool 
it  furnishes  a  useful  lubricant. 

Sterile  Linen. — At  the  moment  of  delivery  the  patient's 
genital  tract  should  be  surrounded  and  protected  by  sterile 
linen.  Large  pads  of  sterile  cheesecloth  and  cotton  are  useful, 
upon  which  the  patient  may  lie.  The  abdomen  may  be 
covered  with  a  sterile  sheet.  At  the  moment  of  delivery 


316  MANUAL   OF   OBSTETRICS 

the  limbs  should  be  covered  by  sterile  linen  leggings  which 
terminate  at  the  upper  extremity  in  a  square  of  sterile  linen 
sufficiently  large  to  cover  the  lower  abdomen  and  pubic  region. 
This  operating  sheet,  as  it  is  sometimes  called,  cannot  be- 
come disarranged  during  labor,  but  completely  covers  the 
limbs,  abdomen  and  pubes.  It  is  sterilized  in  hospital  and 
carried  in  a  sealed  package  with  other  appliances. 

If  the  use  of  the  rubber  pad  is  preferred  this  should  be 
thoroughly  cleaned  with  soap  and  water  and  lysol,  and  may 
be  covered  with  comfort  to  the  patient  by  a  sterile  linen 
cover. 

In  addition  to  those  instruments  which  are  strictly  obstet- 
rical, two  hypodermic  syringes  in  good  working  order  should 
be  invariably  at  hand  for  confinement.  If  the  obstetrician 
is  to  go  some  distance  from  his  office,  a  small  metal  box 
containing  instruments  for  performing  bleeding  and  intra- 
venous saline  transfusion  may  be  of  great  value.  So  the 
necessary  tube  and  funnel  for  washing  out  the  stomach  and  a 
rectal  tube  may  be  urgently  needed  in  complicated  cases. 

THE  PATIENT'S  ROOM  AND  ITS  FURNITURE 

For  confinement  and  the  puerperal  period  a  room  in  an  up- 
per story,  well  aired  and  lighted  and  exposed  to  the  sun  in  all 
but  the  hottest  weather,  should  be  selected.  A  bathroom 
on  the  same  floor  is  necessary  but  it  should  not  immediately 
adjoin  the  room  of  the  patient.  A  separate  room  for  the 
child  and  nurse  will  be  of  great  value.  The  patient's  room 
if  possible  should  have  an  open  fireplace  where  a  wood  fire 
can  be  used. 

Care  should  be  taken  that  there  has  been  no  infectious 
illness  in  the  room  preceding  the  patient's  confinement,  and 
that  curtains  and  hangings  and  upholstered  furniture,  if 
possible,  should  be  removed  before  confinement.  If  an  old 
carpet  be  nailed  down  upon  the  floor  that  portion  of  the  room 
occupied  by  the  patient's  bed  and  about  it,  should  be  covered 
by  old  sterile  sheets  at  the  time  of  confinement.  The  dust 
from  an  old  carpet  is  a  source  of  danger  in  all  surgical  pro- 
cedures. At  the  time  of  confinement  the  nurse  will  need 
several  medium-sized  firm  stands,  chairs  with  wooden  bot- 


DRESSINGS  317 

toms,  an  abundant  supply  of  hot  and  cold  boiled  water,  and 
a  means  of  heating  the  room  promptly  just  before  the  birth 
of  the  child. 

The  patient's  bed  should  be  narrow  and  high  and  the  mat- 
tress firm.  Good  results  can  often  be  obtained  by  raising  a 
single  bed  upon  four  cubical  wooden  blocks,  8  inches  in  di- 
ameter. The  bed  should  stand  in  such  a  position  that  it  is 
easily  accessible  from  all  directions.  An  iron  hospital  bed  is 
excellent  for  the  purpose,  and  in  a  large  family  may  be  useful 
in  subsequent  illness.  The  mattress  must  be  protected  by 
impervious  material  and  the  bed  practically  made  up  double, 
so  that  after  the  confinement  soiled  linen  and  protective  can 
be  removed,  leaving  the  patient  in  a  clean  bed.  The  blan- 
kets used  during  confinement  should  not  be  large  or  very 
heavy  and  should  be  sterilized  if  possible  before  they  are  used. 
Small  and  firm  pillows  will  be  found  better  than  the  larger 
and  softer  variety.  A  large  and  firm  screen  is  a  great  com- 
fort in  the  puerperal  patient's  room  and  is  useful  for  the 
nurse  in  caring  for  the  child. 

DRESSINGS 

While  it  is  not  practical  to  cover  the  patient  completely 
in  sterile  garments  during  labor,  still  those  which  are  un- 
doubtedly clean  must  be  selected.  Old  linen  should  be  em- 
ployed, so  that  linen  garments  can  be  torn  if  necessary  when 
it  is  desirable  to  remove  them  while  the  patient  is  weak. 

Obstetrical  dressings  consist  of  bandages  for  the  breasts, 
and  an  abdominal  binder  and  occlusion  dressings  for  the  vulva, 
which  are  retained  in  position  by  a  T-bandage.  The  breast 
and  abdominal  binders  and  the  T-bandage  may  be  made 
,  of  unbleached  muslin  which  has  been  sterilized  by  boiling. 
Vulvar  occlusion  dressings  may  be  conveniently  made  with 
gauze,  enclosing  borated  or  sterile  cotton. 

Where  expense  is  a  great  item,  cotton  padding  with  a 
centre  portion  of  picked  oakum  enclosed  in  sterile  cheese- 
cloth, may  be  used.  It  is  the  duty  of  the  obstetric  nurse 
to  visit  her  patient  before  confinement  and  see  that  dressings 
are  ready,  sterilized,  wrapped  in  sterile  packages,  and  suit- 
ably labelled  and  put  in  a  proper  receptacle.  The  character 
of  the  dressings  will  depend  considerably  upon  the  patient's 


318  MANUAL   OF   OBSTETRICS 

necessity  for  economy.     Efficient  dressings  can  be  prepared 
very  cheaply,  if  such  be  desired. 

THE  OBSTETRIC  LIST 

Obstetricians  are  accustomed  to  furnish  the  patient  with  a 
list  of  articles  which  should  be  in  readiness  before  confine- 
ment. Such  lists  differ  with  the  ideas  of  different  obstetri- 
cians. The  most  elaborate  lists  specify  basins  and  pitchers  of 
granite  or  other  ware,  gauze  and  bandages,  and  binders,  anti- 
septics, as  bichloride  tablets  or  lysol,  soap,  nail  brushes, 
whiskey  or  brandy,  material  for  tying  the  umbilical  cord  of 
the  child,  borated  cotton,  a  preparation  of  opium,  and  often 
strychnia  and  some  preparation  of  digitalis  and  of  ergot. 
One  or  two  catheters  for  the  mother's  use,  a  breast-pump, 
safety-pins,  an  ointment  for  the  nipples,  and  scales  for  weigh- 
ing the  child. 

Supplies  for  the  Infant. — It  is  the  part  of  the  obstetrician 
to  see  that  clothing  prepared  for  the  infant  is  adapted  to  its 
needs.  Thin  woolen  shirts,  thin  woolen  abdominal  bands 
and  socks,  white  and  flannel  slips,  linen  or  muslin  dresses,  a 
cap,  and  wraps  for  going  out  of  doors,  a  solution  to  be  used 
for  cleansing  the  mouth,  and  one  to  be  dropped  into  the  eyes, 
sterilized  soft  old  linen  for  cleaning  the  mouth  and  about 
the  eyes,  ligature  material  for  tying  the  umbilical  cord,  blunt 
pointed  scissors  for  cutting  the  cord,  medicine  droppers,  a 
suitable  crib  or  bassinette,  several  sponges  or  wash-cloths,  a 
fresh  cake  of  castile  soap,  a  saturated  solution  of  boracic  acid, 
should  all  be  in  readiness. 

The  room  to  be  occupied  by  the  child  and  nurse  should 
be  sunny  and  airy,  if  possible,  having  an  open  fire,  and  in 
a  thoroughly  clean,  simple  and  aseptic  condition. 

Communication  with  the  Obstetrician. — It  is  of  the  greatest 
importance  that  the  obstetric  nurse  should  have  convenient 
means  for  communicating  with  the  obstetrician  at  any  time. 
Quick  telephone  service,  if  possible,  should  be  procured,  but 
if  this  cannot  be  obtained  a  messenger  should  be  put  at  her 
disposal  at  any  time  during  the  confinement. 

Hot  Water  and  Heat. — The  obstetric  nurse  should  at 
any  time,  day  or  night,  be  able  to  regulate  the  heat  of  the 
patient's  room  and  to  secure  a  practically  unlimited  supply 


THE    OBSTETRIC   LIST  319 

of  hot  boiled  water.  If  there  has  been  an  epidemic  of  illness 
in  the  neighborhood  of  an  infectious  character  no  water 
should  be  used  about  the  patient  in  any  way  which  has  not 
been  thoroughly  boiled. 

Directions  Concerning  Confinement. — It  is  very  important 
that  the  obstetrician  give  to  the  nurse  precise  directions  as 
to  when  he  is  to  be  summoned,  and  under  what  circumstances, 
when  the  patient  comes  into  labor.  The  nurse  should  be 
instructed  about  any  special  indications  which  are  of  im- 
portance in  a  given  case,  should  be  told  what  to  look  for, 
and  under  what  conditions  to  send  messages.  The  family 
must  be  impressed  with  the  necessity  for  sending  messages 
at  once. 

It  is  well  to  have  an  understanding  concerning  who  is  to 
have  access  to  the  confinement  room  during  the  patient's 
labor.  In  the  interests  of  the  patient,  the  obstetrician,  and 
the  nurse,  relatives  are  most  useful  when  absent,  but  the  pa- 
tient may  demand  that  someone  be  present  during  her  con- 
finement. The  same  definite  arrangement  should  obtain 
between  the  obstetrician  and  the  nurse  regarding  visitors 
during  the  puerperal  period.  Many  patients  are  greatly 
disturbed,  and  their  convalescence  retarded,  by  visitors  who 
insist  upon  talking  with  them,  and  inspecting  and  disturbing 
the  child.  While  the  duty  may  be  a  disagreeable  one,  it  is 
the  part  of  the  obstetrician  to  protect  his  patient,  with  the 
help  of  the  nurse,  from  intrusion. 


PART  V 

OBSTETRIC  OPERATIONS  (OBSTETRIC 
SURGERY) 


As  other  branches  of  surgery  have  advanced  and  better 
results  have  been  obtained,  so  obstetric  surgery,  by  adopting 
the  same  methods  successful  in  other  branches,  shows  equally 
good  results. 

While  it  is  not  the  desire  of  the  obstetrician  to  unduly 
alarm  the  patient  or  her  relatives,  or  to  magnify  his  services, 
the  relatives  of  patients  should  be  made  to  understand  that 
obstetric  operations  are  as  serious  and  important  as  those  of 
other  branches  of  surgery,  and  that  their  successful  perform- 
ance demands  the  same  aseptic  technique,  skilled  assistants, 
anesthesia,  and  aseptic  environment,  with  the  necessary 
instruments  and  appliances  for  meeting  complications  which 
make  the  operations  of  general  surgery  safe  and  successful. 
Obviously  the  more  difficult  and  more  important  obstetric 
operations  must  be  done  in  hospital. 

Those  patients  in  whom  a  diagnosis  is  made  during  preg- 
nancy of  some  condition  liable  to  cause  complications  in 
labor  should  go  to  hospital  for  confinement.  With  the  in- 
creasing number  of  hospitals,  good  roads  and  motor  vehicles 
the  most  complicated  cases  can  be  safely  transported. 

When,  however,  the  patient  must  remain  at  home  the 
obstetrician  must  establish  practically  the  aseptic  technique 
of  the  hospital  in  the  patient's  house. 

To  do  this,  in  addition  to  the  patient's  nurse,  a  nurse  ac- 
customed to  clinical  work  is  most  desirable.  She  will  under- 
stand sterilizing  instruments  and  appliances  and  how  to 
prepare  the  operating  table,  and  the  preparation  of  the  pa- 
tient. A  thoroughly  competent  anesthetizer  accustomed 

320 


OBSTETRIC    OPERATIONS 


321 


to  obstetric  work  is  indispensable.  If  abdominal  section  is 
to  be  performed,  additional  assistance  will  be  necessary. 

For  difficult  forceps  deliveries,  craniotomy,  and  sections, 
if  the  operator  does  not  bring  an  operating  table  one  must  be 
improvised  by  taking  a  kitchen  table.  This  must  be  washed 
clean,  covered  with  blankets  and  then  with  sterile  material. 

To  hold  the  patient's  limbs  in  a  convenient  position  a 
large  sheet  folded  in  the  longest  way  should  be  placed  be- 
neath the  occiput  and  over  the  shoulders,  the  patient  placed 
upon  the  back,  the  thighs  and  legs  completely  flexed,  and 


Fig.    114. — Aseptic  preparation  for  an  obstetric  operation.     Vaginal 

delivery. 

the  sheet  tied  around  the  outer  portion  of  each  leg  just  be- 
low the  knee.  This  simple  device  enables  the  obstetrician 
to  dispense  with  the  services  of  those  who  would  hold  the 
patient's  limbs. 

For  operations  in  private  houses  the  obstetrician  must 
bring  with  him  instruments  and  appliances,  sterilizer,  sterile 
emergency  dressings,  an  operation  sheet  for  covering  the 
limbs  and  abdomen,  operating  gowns,  gloves,  instruments 
for  transfusion,  for  irrigating  the  stomach  and  intestine, 


322  MANUAL   OF   OBSTETRICS 

and  clean  or  sterile  operating  suits.  The  anesthetizer 
should  be  responsible  for  stimulants  and  anesthetics. 

If  there  be  sufficient  time,  an  operating  room  may  be  im- 
provised by  removing  unnecessary  furniture,  thoroughly 
airing  and  warming  the  room  and  covering  the  floor  about 
the  operating  table  with  old  sheets  sterilized  or  dried  from 
bichloride  solution.  During  operation  the  windows  should  be 
so  screened  that  neighbors  cannot  observe  what  is  going  on. 

In  conducting  obstetric  operations  the  obstetrician  must 
remember  that  he  assumes  grave  responsibilities  in  their  per- 
formance. Unless  in  some  sudden  and  dangerous  emergency, 
he  is  not  justified  in  performing  obstetric  operations  without 
notifying  the  husband  or  nearest  relative.  While  it  is  un- 
necessary to  go  into  details,  the  necessity  for  operation  must 
be  clearly  stated,  and  permission  from  those  responsible  for 
the  patient  should  be  obtained.  Should  operation  threaten 
the  life  of  the  child,  and  the  parents'  religious  belief  causes 
them  to  desire  baptism,  some  provision  must  be  made  for 
the  administration  of  this  rite. 

In  cases  of  craniotomy,  or  the  birth  of  a  monster,  care  must 
be  taken  to  cover  the  body  of  the  child  and  not  to  permit  the 
mother  or  other  relatives  to  observe  its  distressing  appear- 
ance. In  the  event  of  abnormality  or  a  monster  the  husband 
or  nearest  relative  of  the  patient  should  be  shown  the  child 
and  the  condition  explained. 

When  it  becomes  necessary  to  transport  obstetrical  pa- 
tients to  hospital  it  may  often  be  well  to  give  a  hypodermatic 
injection  of  morphin  and  atropin  before  the  patient  is 
placed  in  the  ambulance.  Labor  pains  are  sometimes  ag- 
gravated and  the  patient  suffers  much  increased  pain  by 
the  motion  of  the  vehicle.  Precautions  must  be  taken  to 
guard  obstetric  patients  from  cold  and  exposure. 

In  justice  to  the  patient  and  the  profession,  obstetric  op- 
erations must  be  performed  with  the  same  thoroughness 
and  care  given  to  major  surgery.  The  patient  and  her 
friends  must  understand  the  gravity  of  these  procedures  and 
proper  compensation  for  them  should  be  given  to  operators, 
assistants,  and  nurses. 


CHAPTER  XVIII 
THE  FORCEPS 

The  most  common  and  one  of  the  most  important  opera- 
tions of  obstetric  surgery  is  the  delivery  of  the  child  by  for- 
ceps. It  is  unnecessary  to  state  the  different  varieties  and 
modifications  of  this  important  instrument.  No  forceps 
can  be  considered  satisfactory  which  is  not  carefully  made, 
perfectly  plated,  and  so  constructed  that  some  device  for 
making  axis  traction  can  be  attached.  Of  the  many  sorts, 
unquestionably  in  English  speaking  countries,  the  Simpson 
forceps  is  most  used.  As  obstetric  surgery  has  improved, 
the  application  of  forceps  to  the  unengaged  head  has  been 
abandoned.  The  elaborate  and  efficient  instrument  of  Tarnier 
is  rarely  used.  We  have  found  most  efficient  Simpson's  for- 
ceps, made  sufficiently  long  to  reach  the  head  and  engage  in 
the  pelvic  brim,  and  strong  enough  to  enable  the  maker  to 
perforate  the  blades  for  the  attachment  of  tapes  for  axis 
traction. 

The  forceps  is  composed  of  three  portions:  The  cephalic 
extremity  which  fits  on  the  head,  the  shank  or  narrow  por- 
tion upon  which  is  the  lock  and  the  handles.  The  cephalic 
portion  should  be  so  shaped  that  it  fits  accurately  over  the 
parietal  portion  of  the  fetal  head  at  term.  The  lock  of  the 
forceps  should  be  of  the  simplest  construction  so  that  the 
instrument  can  be  locked  or  loosened  with  the  least  possible 
disturbance.  The  handles  should  be  large  enough  to  per- 
mit a  firm  grasp  in  a  large  hand. 

Among  the  many  devices  for  making  axis  traction  the 
tapes  originally  proposed  by  Poulet  have  been  found  useful. 
Good  forceps  have  a  proper  cephalic  curve  with  the  blades 
so  thoroughly  made  that  they  will  not  bend  or  break,  the 
lock  accurately  fitted,  the  handles  light  and  large,  and  the 
whole  instrument  well  protected  by  nickel  plating.  While  a 

323 


324  MANUAL    OF    OBSTETRICS 

traction  bar  is  sometimes  useful,  in  many  cases  it  is  super- 
fluous. 

Where  forceps  are  improperly  made  the  instrument  has 
broken,  leaving  a  portion  within  the  womb,  or  has  bent  so 
that  the  original  curve  has  been  lost.  For  convenience  the 
handles  may  be  hollow  or  made  largely  of  aluminum. 

The  Indications  for  Delivery  by  Forceps. — In  common  with 
other  important  obstetric  operations,  delivery  by  forceps 
is  indicated  when  the  life  or  health  of  the  mother  or  of  the 
child  is  in  danger.  Safe  delivery  by  forceps  is  only  possible 
where  the  head  is  well  engaged  and  has  moulded,  and  is  in  a 
position  and  with  a  presentation  favorable  for  vaginal  delivery. 
If  the  forceps  be  applied  to  the  head  before  engagement 
and  moulding,  with  unfavorable  presentation  and  position, 
the  life  of  the  child  is  lost,  and  the  life  of  the  mother 
gravely  threatened. 

The  most  common  indication  for  forceps  delivery  is  failure 
in  the  mother's  expulsive  forces,  causing  delay  which  threat- 
ens the  life  of  the  child  and  the  health  of  the  mother.  Some 
observers  state  that  simple  inertia  of  the  uterus  and  muscles 
of  parturition  is  never  a  valid  cause  in  itself  for  forceps  ex- 
traction. While  we  may  not  agree  entirely  with  this,  for 
successful  forceps  delivery  it  is  necessary  that  the  patient's 
uterus  contract  during  and  after  the  delivery  of  the  child. 
If  a  patient  was  so  exhausted  in  labor  that  uterine  contrac- 
tions had  absolutely  ceased,  it  would  be  necessary  for  the 
obstetrician  to  give  anodynes  and  stimulants  until  the  pa- 
tient's uterus  acted  before  she  could  be  safely  delivered. 

The  child  must  also  be  living  and  in  good  condition  to 
justify  the  use  of  forceps.  If  the  child  has  died,  in  many 
cases  the  mother  can  more  safely  be  relieved  of  the  infant 
by  embryotomy.  While  this  is  true  from  the  standpoint  of 
science,  the  mutilation  of  the  child  which  accompanies  embry- 
otomy renders  it  an  operation  of  horror  among  patients, 
and  the  feelings  of  a  mother  would  be  less  shocked  if  the 
child  was  delivered  by  forceps  without  mutilation,  although 
dead,  than  if  the  dead  child  had  embryotomy  and  delivery. 

It  is  seldom  necessary  to  explain  to  the  mother  the  exact 
nature  of  the  operation  to  be  performed.  Her  suffering 
is  so  great  that  she  welcomes  relief  by  any  method  which 


THE    FORCEPS  325 

gives  a  prospect  of  success  for  her  and  for  the  child.  To 
responsible  relatives,  however,  a  clear  statement  should  be 
made  and  such  encouraging  facts  as  are  available  should  lie 
stated  regarding  the  outcome  of  the  operation. 

In  addition  to  the  essential  conditions  that  engagement  and 
moulding  must  be  present,  the  cervix  must  be  dilated  two- 
thirds.  It  is  desirable  that  full  dilatation  be  present  and  the 
membranes  ruptured,  but  where  the  necessity  for  delivery 
by  forceps  arises,  if  two-thirds  dilatation  l>e  present  the  re- 
mainder can  be  effected  under  anesthesia  by  the  gloved  hand, 
the  membranes  ruptured,  and  the  forceps  applied. 

It  has  properly  been  said  that  the  use  of  forceps  is  the 
most  dangerous  and  deadly  operation  in  obstetric  practice. 
This  is  true  if  the  operation  be  done  without  proper  indica- 
tions and  without  the  conditions  necessary  for  success.  It  is 
of  absolute  importance  that  the  head  be  well  engaged  and 
moulded,  for  this  is  a  practical  demonstration  of  the  fact 
that  the  mother's  birth  canal  and  the  fetus  are  proportionate 
in  size.  Where  this  essential  condition  is  not  present  and  a 
mistaken  diagnosis  is  made,  the  lives  of  mother  and  child 
are  in  danger. 

The  Forceps  as  an  Instrument. — While  there  are  many 
varieties  of  forceps  offered  for  sale,  but  few  will  fill  the  indi- 
cations. Good  forceps  should  have  a  proper  cephalic  and 
pelvic  curve,  should  be  made  of  the  best  steel,  well  plated, 
and  should  have  a  lock  which  can  easily  be  closed  and  opened ; 
and  with  the  forceps  should  be  some  simple  and  practical 
device  for  pulling  downward  and  backward  in  the  axis  of  the 
birth  canal.  The  forceps  should  be  long  enough  to  insert 
the  cephalic  extremity  of  the  blades  into  the  brim  of  the  pel- 
vis, but  it  is  not  necessary  that  the  forceps  should  be  intro- 
duced above  the  brim. 

Two  instruments  are  typical  of  the  forceps  in  use  at  the 
present  day:  First  is  Simpson's,  which  has  a  well-marked 
pelvic  and  cephalic  curve,  a  lock  easily  closed  and  opened, 
and  to  which  an  axis  traction  device  can  be  attached  with 
but  little  difficulty.  If  the  forceps  be  made  somewhat  heav- 
ier than  ordinary,  and  the  middle  of  the  cephalic  portion 
of  the  blades  be  perforated  for  the  use  of  strong  linen 
tape,  a  pull  directly  downward  and  backward  is  obtained 


326  MANUAL   OF   OBSTETRICS 

which  well  fulfils  the  indications  for  axis  traction.  A  trac- 
tion bar  through  which  the  tapes  may  be  attached  may  ac- 
company the  instrument,  while  the  operator  may  grasp  the 


Fig.  115. — Simpson  forceps  with  tapes  for  making  axis  traction. 

tapes  in  one  hand,  holding  the  instrument  by  the  hand  with 
the  other.  This  forceps  is  undoubtedly  more  in  use  than 
any  other  among  English  speaking  physicians.  Where  it  is 


Fig.  116. — Simpson  forceps.     Axis-traction  tapes  and  traction  bar. 

desired  to  use  axis  traction  by  clamping  the  forceps  upon  the 
child's  head,  the  Tarnier  forceps  is  best  adapted  for  this  pur- 


THE    FORCEPS  327 

pose.  This  is  longer,  heavier,  more  elaborate  in  construction, 
and  is  adapted  for  application  to  the  sides  of  the  head,  where 
it  is  fastened  by  a  lock  and  binding  screw.  The  forceps 
and  head  rotate  together  as  one  body,  and  traction  is  made 
downward  and  backward  by  steel  traction  bars  attached  to  a 
handle  with  a  universal  joint. 

The  Tarnier  forceps  is  especially  useful  in  some  cases  where 
the  head  engages  and  moulds  but  does  not  descend,  and 
where  in  a  primiparous  patient  the  birth  canal  has  not  been 
dilated  by  previous  parturition.  If  the  Tarnier  forceps 
be  applied  accurately  to  the  sides  of  the  head,  the  head  can 
be  brought  down  upon  the  pelvic  floor,  the  forceps  then  re- 
moved, and  the  head  expelled  spontaneously;  or  the  for- 
ceps retained  and  the  head  delivered. 

The  Simpson  forceps  is  especially  useful  for  cases  of  trans- 
verse position  of  the  head,  deficient  rotation,  a  tendency  to 
backward  rotation  of  the  occiput  or  occipito-posterior,  and 
where  the  head  is  already  upon  the  pelvic  floor.  Unques- 
tionably this  instrument  is  useful  in  the  greater  proportion 
of  cases  requiring  forceps  delivery. 

The  Operation  of  Forceps  Delivery. — This  obstetric  oper- 
ation cannot  be  safely  and  properly  done  unless  the  same  pre- 
cautions are  taken  which  are  observed  in  other  surgical  pro- 
cedures. When  the  indications  for  operation  are  clear  the 
operator  will  require  an  assistant  who  is  not  only  skilled  in 
giving  anesthetics,  but  who  has  had  obstetric  experience  and 
understands  the  behavior  of  the  uterus  in  labor.  In  addition 
to  the  nurse  who  has  charge  of  the  patient,  a  nurse  or  assistant 
who  takes  charge  of  the  instruments,  sutures  and  dressings, 
is  desirable.  A  sterilizer,  the  obstetric  forceps,  hemostats, 
scissors,  needles,  suture  material,  forceps  for  introducing 
gauze  packing,  hypodermatic  syringes  in  good  order,  iodo- 
form,  sterile  and  bichloride  gauze,  antiseptics,  especially 
lysol,  a  sterile  fountain  syringe  with  a  sterile  glass  nozzle 
sufficiently  long  to  irrigate  the  uterus  if  necessary,  operating 
suits,  gowns,  and  rubber  gloves,  and  an  apparatus  for  giving 
an  anesthetic,  are  essential. 

A  suitable  table  may  usually  be  improvised  in  the  house  of 
the  patient,  but  some  operators  prefer  to  carry  an  operating 
table.  A  room  should  be  chosen,  if  possible,  next  the  pa- 


328  MANUAL   OF   OBSTETRICS 

tient's,  where  the  table  may  be  placed  in  a  good  light,  with 
smaller  tables  for  basins,  pitchers,  and  other  appliances.  A 
gallon  of  hot  sterile  1  per  cent,  lysol  should  be  in  readiness, 
and  tincture  of  green  soap  and  lysol  or  bichloride  solution 
should  also  be  at  hand.  Sterile  gauze  or  cotton  for  sponging 
will  be  needed. 

To  retain  the  patient's  limbs  in  position  a  sheet  folded  the 
longest  way  should  be  laid  across  the  table  beneath  her  neck, 
and  when  she  is  anesthetized  the  limbs  should  be  drawn  up 
upon  the  abdomen,  the  ends  of  the  sheet  passed  over  the 
shoulders  and  tied  firmly  on  the  outer  side  of  each  leg  below 
the  knee.  This  rotates  the  legs  and  thighs  outward.  The 
patient  may  be  anesthetized  in  her  bed,  ether  being  the  an- 
esthetic of  choice,  and  may  then  be  lifted  upon  the  table  in 
the  adjoining  room.  When  the  limbs  are  in  position  by 
the  sheet,  the  patient  should  be  catheterized  under  anes- 
thesia and  with  antiseptic  precautions.  The  hair  about  the 
external  genitals  should  be  closely  trimmed  with  scissors, 
the  external  parts  thoroughly  cleansed  with  tincture  of  green 
soap  and  water,  followed  by  flushing  with  sterile  hot  water 
and  then  with  bichloride  solution  1 : 4000.  A  copious  but 
gentle  vaginal  irrigation  of  1  per  cent,  lysol  should  be  given. 

The  nurse  in  charge  of  the  patient  may  assist  in  holding 
the  limbs  steadily  and  should  be  in  readiness  to  receive  the 
child  and  to  care  for  it.  The  instruments  employed,  in 
charge  of  the  other  nurse  or  assistant,  should  be  placed  con- 
veniently for  the  operator.  Anesthesia  should  be  at  first 
surgical  anesthesia,  and  before  applying  the  forceps  the  oper- 
ator should  make  a  thorough  examination  with  the  gloved 
hand  to  determine  the  exact  position  of  the  presenting  part. 
Having  found  that  engagement  and  moulding  are  present 
and  having  mapped  out  the  head,  the  left  blade  of  the  for- 
ceps with  its  axis  traction  attachment  should  then  be  taken 
in  the  left  hand  of  the  operator,  and  the  right  hand  inserted 
up  to  the  thumb,  which  acts  as  a  guard.  A  common  mis- 
take consists  in  inserting  but  one  or  two  fingers,  so  that  the 
forceps  blade  is  introduced  more  or  less  blindly,  and  in  un- 
skilful hands  may  be  thrust  through  the  vagina  and  into  the 
pelvic  or  abdominal  cavity. 

Care  should  be  taken  that  the  membranes  have  ruptured 


THE    FORCEPS 


329 


and  that  the  forceps  is  applied  directly  to  the  fetal  head.  If 
dilatation  is  not  perfectly  complete  it  is  well  to  pass  the 
gloved  hand  around  the  entire  cervix,  stretching  it  gently 
but  thoroughly.  The  left  blade  of  the  forceps  is  passed 
along  the  right  as  a  guard  and  is  applied  as  accurately  as 
possible  over  the  parietal  portion  of  the  head.  Should  the 
face  be  presenting,  the  forceps  is  applied  over  the  sides  of  the 
head  and  face.  Should  the  breech  be  presenting,  the  for- 
ceps is  applied  over  the  trochanteric  region. 

It  is  well  to  notice  the  position  which  the  forceps  blade 
tiikos  after  application,  as  this  is  a  valuable  index  of  the  posi- 
tion of  the  head.  The  right  blade  is  then  taken  in  the  right 


Fig.  117. — Forceps  applied  to  the  sides  of  the  child's  head. 

hand  of  the  operator,  the  left  hand  introduced  as  a  guide, 
and  the  blade  passed  along  the  hand  and  on  the  side  of  the 
head.  It  is  gently  and  slowly  moved  until  it  comes  in  rela- 
tion with  the  other  part,  so  that  locking  easily  is  possible. 
It  may  be  necessary  to  slightly  move  both  blades  of  the  for- 
ceps before  this  can  safely  be  done.  Under  no  circumstances 
should  the  forceps  be  brought  with  great  force  together,  and 
if  the  instrument  does  not  readily  lock  the  application  is  an 
improper  and  unsafe  one. 

Before  making  traction  the  operator  must  satisfy  himself 
by  examination  that  nothing  but  the  fetal  head  is  in  the 
grasp  of  the  forceps.  Occasionally  the  cervix  is  caught 


330 


MANUAL   OF   OBSTETRICS 


in  such  a  manner  as  to  lacerate  it,  and  other  injuries  are 
sometimes  inflicted  upon  the  mother's  soft  tissues.  When  it 
is  found  that  the  application  is  correct  the  axis  traction  at- 
tachment is  brought  into  proper  position. 

In  using  the  Simpson  forceps  with  tapes,  a  finger  of  the 
operator  may  be  placed  between  the  distal  extremities  of  the 
blades  at  the  handles.  As  the  operator  pulls  the  pressure  of 
the  handles  upon  the  finger  will  give  some  indication  of  the 
pressure  exerted  by  the  instrument  upon  the  child's  head. 
In  this  manner  injurious  pressure  may  often  be  avoided. 


Fig.  118. — Axis  traction  with  Simpson  forceps  and  tape  attachment. 

This  is  especially  valuable  in  cases  where  by  reason  of  the 
abnormal  position  of  the  head  the  blades  have  not  been  ac- 
curately applied  to  the  sides  of  the  head,  and  where  traction 
must  be  made,  and  the  head  allowed  to  rotate  in  the  forceps 
blades  between  the  tractions. 

Delivery  by  Forceps. — The  forceps  is  designed  to  supple- 
ment the  forces  of  labor,  and  to  do  this  properly  the  uterus 
must  be  made  to  act  while  the  forceps  is  making  traction. 

The  assistant  who  is  anesthetizing  the  patient  should  rub 
the  uterus  and  excite  uterine  contractions  just  before  the 
operator  makes  his  traction.  The  uterus  is  thus  stimulated 


THE    FORCEPS 


331 


to  follow  the  head  down,  and  the  tendency  to  relaxation  and 
hemorrhage  is  much  less.  Traction  should  be  made  with  the 
arms  only,  without  pulling  or  bracing,  and  by  the  axis  trac- 
tion attachment  the  direction  of  the  pull  should  be  downward 
and  backward.  In  cases  of  deficient  rotation  the  position 
of  the  instrument  will  serve -as  an  index  to  the  movement  of 
the  head.  After  a  reasonable  traction  has  been  made  the 
operator  should  desist  and  loosen  the  grasp  of  the  forceps. 
Traction  should  be  repeated  at  intervals  of  a  few  minutes. 


Fig.  119. — Patient  delivered  in  left  lateral  posture  with  axis-traction 

forceps. 

always  supplemented  by  contraction  of  the  uterus,  until 
the  head  has  rotated  and  the  occiput  appears  beneath  the 
pubes. 

While  some  advise  at  this  stage  that  the  instrument  be  re- 
moved and  the  patient  allowed  to  become  conscious  and 
deliver  herself  it  is  usually  better  to  proceed  and  to  complete 
the  delivery.  When  the  head  is  well  upon  the  pelvic  floor 
with  the  occiput  under  the  pubes  axis  traction  is  not  needed. 
If  tapes  have  been  used  they  may  be  dropped  or  cut,  and  if 


332  MANUAL   OF    OBSTETRICS 

the  Tarnier  forceps  has  been  used  the  traction  bar  should  be 
removed  and  the  traction  rods  brought  up  under  the  blades. 
To  deliver  the  head  over  the  perineum  and  pelvic  floor 
with  the  forceps  the  operator  must  prepare  to  support  the 
pelvic  floor  to  some  extent  and  to  guard  against  contamina- 
tion of  the  birth  canal  from  bacteria  and  fecal  matter  from 
the  bowels.  To  accomplish  this  the  perineum  should  be 


Fig.  120. — The  protection  of  the  pelvic  floor  during  forceps  delivery. 

thoroughly  cleansed  with  warm  bichloride  or  lysol,  and  a 
large  pad  of  gauze  wrung  out  of  bichloride  or  lysol  should  be 
placed  over  the  anus.  With  successive  and  gentle  tractions 
the  occiput  should  be  brought  well  under  the  pubes  with  the 
forceps  grasped  in  one  hand,  while  with  the  other  placed  upon 
the  pad  of  gauze,  the  perineum  and  pelvic  floor  should  be 
stretched  backward  over  the  head.  With  a  few  tractions  it 


THE    FORCEPS  333 

will  be  possible  in  this  manner  to  deliver  the  head  over  the 
perineum  and  pelvic  floor.  When  the  head  has  been  de- 
livered the  forceps  is  removed  and  the  remainder  of  the  de- 
livery accomplished  as  in  normal  cases. 

After  the  child  is  delivered  the  operator  must  use  his  judg- 
ment, and  in  almost  all  cases  it  is  possible  to  allow  the  pa- 
tient to  become  at  least  partially  conscious  and  to  secure  good 
uterine  contractions  for  the  delivery  of  the  placenta.  This 
should  be  aided  by  Crude's  method  of  expression. 

It  is  well  to  keep  the  patient  partially  anesthetized  as  it 
may  be  necessary  to  take  stitches,  when  she  must  be  under 
complete  control.  After  the  placenta,  membranes  and  cord 
have  been  delivered,  if  the  labor  has  been  long,  with  repeated 
examinations  and  the  forceps  introduced  within  the  cervix 
and  in  the  pelvic  brim,  it  is  well  to  thoroughly  irrigate  the 
uterus  with  hot  1  per  cent,  lysol. 

To  avoid  relaxation  and  hemorrhage  and  infection,  the 
uterus  may  be  tamponed  to  advantage  with  10  per  cent, 
iodoform  gauze.  The  cervix  should  then  be  drawn  down 
by  tenaculum  forceps,  and  examined  to  determine  lacerations. 
If  such  be  present  they  should  immediately  be  closed  with 
No.  2  chromicized,  iodized  or  sterile  catgut.  Both  segments 
of  the  pelvic  floor  should  then  be  examined  and  lacerations 
immediately  repaired.  The  closure  of  any  lacerations  in 
the  perineum  and  the  tamponing  of  the  vagina  with  moderate 
firmness  by  bichloride  gauze  completes  the  operation. 

The  Forceps  in  Abnormal  Rotation  of  the  Occiput. — This 
is  one  of  the  most  troublesome  conditions  which  the  obste- 
trician has  to  encounter,  and  one  in  which  the  forceps  is  often 
used.  Resort  should  not  be  had  to  the  forceps  until  a  reason- 
able effort  has  been  made  to  cause  anterior  rotation.  The 
patient  should  be  placed  upon  the  side  toward  which  the 
back  is  pointing,  the  urinary  bladder  emptied  if  necessary  by 
catheter,  and  tonic  doses  of  strychnia  given  to  secure  effi- 
cient uterine  contractions. 

The  action  of  pituitrin  is  too  violent  and  brief  for  this  pur- 
pose. A  small  quantity  of  brandy  and  aromatic  spirits  of 
ammonia  may  be  given  by  the  mouth.  In  many  cases  uter- 
ine contractions  are  stimulated  and  anterior  spontaneous 
rotation  results.  When  this  fails,  and  the  indications  point 


334  MANUAL   OF   OBSTETRICS 

to  delivery,  the  position  of  the  back  must  be  carefully  as- 
certained. Whenever  possible  forceps  should  be  applied  to 
the  sides  of  the  child's  head,  although  the  head  may  be  stand- 
ing transversely  in  the  pelvic  brim  or  in  the  cavity.  By  using 
axis  traction,  in  the  majority  of  cases  the  head  will  be  brought 
to  the  pelvic  floor  and  thence  will  rotate  in  a  normal  manner. 
Occasionally  reverse  rotation  into  the  hollow  of  the  sacrum 
results. 

It  occasionally  happens  that  the  forceps  cannot  be  ap- 
plied accurately  upon  the  sides  of  the  child's  head.  A  Simp- 
son forceps  may  then  be  applied  along  the  sides  of  the  pelvis 
in  the  pelvic  axis,  grasping  the  head  in  the  best  manner  pos- 
sible. Traction  should  be  made  with  care  and  the  grasp  of 
the  forceps  relaxed  between  each  traction.  The  head  should 
be  brought  to  the  pelvic  floor,  when  it  will  often  rotate  within 
the  forceps  blades,  the  occiput  coming  in  front. 

Rotation  by  the  Forceps. — Some  prefer  in  these  cases  to 
apply  the  narrowest  solid  bladed  forceps  to  the  sides  of  the 
head  and  with  this  instrument  to  rotate  the  head  until  the 
occiput  is  in  front.  The  forceps  is  then  removed,  and  if 
necessary  re-applied.  In  the  hands  of  expert  operators  this 
procedure  is  justifiable,  but  it  is  not  one  to  be  undertaken 
without  especial  skill  and  training. 

The  Forceps  to  the  Posterior  Occiput. — When  the  occiput 
is  turned  directly  behind  in  the  hollow  of  the  sacrum  and  the 
head  is  firmly  down  upon  the  pelvic  floor,  it  may  be  impossible 
to  rotate  the  occiput  in  front.  It  must  then  be  delivered 
posteriorly — a  matter  often  difficult,  and  resulting  inevitably 
in  laceration  to  the  patient. 

To  deliver  the  head  in  this  position,  the  forceps  is  applied 
to  the  sides  of  the  head  and  axis  traction  is  made.  The 
Simpson  forceps,  with  tapes,  attached  to  the  middle  of  the 
cephalic  portion  of  the  blades  has  proved  its  superiority  in 
these  cases,  because  the  traction  is  applied  opposite  the  centre 
of  the  fetal  head,  and  complete  flexion  is  procured.  Unless 
this  be  present,  if  the  head  becomes  partly  extended,  impac- 
tion  of  the  head  and  serious  injury  to  the  mother  may  re- 
sult. 

With  the  occiput  behind,  the  head  is  brought  by  inter- 
mittent traction  firmly  upon  the  pelvic  floor,  until  the  fore- 


THE   FORCEPS 


335 


head  begins  to  be  visible  beneath  the  pubes.  The  occiput 
distends  the  perineum  and  pelvic  floor  to  the  utmost,  and  if 
serious  laceration  be  present  double  episiotomy  is  indicated. 
When  the  forehead  can  be  made  to  pivot  beneath  the  pubes 
the  grasp  of  the  forehead  is  relaxed  and  the  handles  are  car- 
ried backward  in  the  cephalic  portions  of  the  blades,  slightly 
toward  the  pubes.  A  new  grasp  is  then  taken,  and  with  this, 
while  the  forehead  bears  against  the  sub-pubic  ligament, 
the  occiput  is  lifted  as  gently  as  possible  over  the  pelvic  floor. 


Fig.  121. — Posterior  rotation  of  the  occiput.     Delivery  by  forceps  to 
the  sides  of  the  child's  head. 

During  this  procedure  the  anus  should  be  thoroughly  cov- 
ered by  gauze  wrung  out  of  an  antiseptic  solution. 

As  has  been  stated,  laceration  is  inevitable  in  these  cases, 
but  may  be  lessened  by  having  strong  flexion  made  as  the 
head  comes  down,  by  complete  anesthesia  at  the  moment  of 
delivery  and  by  episiotomy. 

Lacerations  extending  to  the  bowel  are  not  uncommon  in 
these  cases,  but  with  good  management  the  lacerations  should 
rarely  open  into  the  bowel.  The  child's  forehead  and  face 
may  be  bruised  because  of  the  pressure  beneath  the  pubes. 


336  MANUAL   OF   OBSTETRICS 

The  Forceps  in  Face  Presentation. — In  face  presentation, 
when  descent  is  delayed,  the  forceps  may  be  applied  to  the 
sides  of  the  head  and  face.  With  axis  traction  complete 
extension  will  be  obtained,  and  the  operator  must  so  guide 
the  head  as  to  bring  the  chin  in  front  beneath  the  pubes. 
The  delivery  of  the  occiput  over  the  perineum  is  done  by 
causing  the  he-ad  to  flex  strongly. 

The  Forceps  in  Breech  Presentation. — In  breech  presenta- 
tion, when  descent  is  delayed,  if  the  forceps  is  used  the  in- 


Fig.  122. — The  use  of  the  forceps  in  face  presentation. 

strument  must  be  applied  over  the  trochanters  and  traction 
made  in  the  axis  of  the  pelvis.  The  operator  usually  pre- 
fers to  remove  the  forceps  so  soon  as  the  breech  is  upon  the 
pelvic  floor,  because  the  breech  and  legs  can  be  manipulated 
more  readily  with  the  hand  than  with  the  forceps. 

Improper  Application  of  the  Forceps. — The  forceps  must 
not  be  applied  to  the  hydrocephalic  head,  nor  to  the  head 
with  the  chin  pointing  in  the  hollow  of  the  sacrum,  nor  to 
the  head  in  brow  presentation,  nor  in  parietal  bone  presen- 
tation. In  none  of  these  cases  will  the  instrument  produce 


THE    FORCEPS 


337 


satisfactory  results,  but  will   injure  the  mother,   and  will 
complicate  her  recovery. 

The  most  common  and  dangerous  error  in  the  use  of  for- 
ceps is  the  failure  to  diagnosticate  the  absence  of  engagement 
and  the  failure  of  moulding.  Because  the  head  has  been 


Fig.  123. — Forceps  applied  to  the  brooch. 

forced  into  the  upper  pelvis  and  has  become  impacted  in  the 
brim,  this  must  not  be  considered  as  engagement.  There 
is  no  moulding  in  these  cases  and  usually  the  head  turns 
transversely.  There  is  increased  lateral  obliquity  and  the 
presentation  of  a  parietal  bone  results. 

22 


338  MANUAL   OF   OBSTETRICS 

Repeated  Application  of  the  Forceps. — Some  obstetricians 
think  well  of  repeated  application  of  the  forceps  in  delayed 
labor.  They  would  bring  the  head  upon  the  pelvic  floor  and 
then  remove  the  instrument,  and  should  normal  expulsive 
force  not  develop,  again  apply  the  forceps  for  delivery. 

This  is  objectionable,  because  it  exposes  the  patient  to  the 
risk  of  repeated  introduction  of  the  forceps,  with  repeated 
examination  and  manipulation. 

The  Successful  Application  of  the  Forceps.— If  the  for- 
ceps has  been  properly  applied  and  the  operator  makes  judi- 
cious traction,  and  the  forceps  slips,  he  may  make  a  thorough 
examination  to  be  sure  that  he  understands  the  position  of 
the  head,  and  must  try  to  shift  the  forceps  slightly  to  ob- 
tain an  accurate  grasp.  If  on  repeated  traction  the 
instrument  slips  the  forceps  must  be  removed  and  the 
attempt  made  to  deliver  by  forceps  must  be  abandoned. 

In  some  cases  of  disproportion  between  mother  and  child, 
where  the  head  is  engaged  but  not  moulded,  some  operators 
permit  a  tentative  traction  with  forceps,  to  observe  whether 
the  head  will  descend  in  the  pelvic  cavity.  This  should  be 
made  with  great  gentleness  and  patience,  and  unless  de- 
scent follows  the  attempt  should  be  abandoned. 

In  some  cases  of  abnormal  rotation  of  the  occiput  it  may 
be  impossible  to  grasp  the  head  in  a  satisfactory  manner 
with  the  forceps.  In  these  cases  the  operator  may  often  fall 
back  upon  internal  podalic  version,  which  will  inevitably 
bring  about  a  position  of  the  body  and  head  more  favorable 
to  the  child. 

In  performing  this  operation  especial  care  must  be  taken 
that  the  patient  be  completely  anesthetized  during  version. 
An  unsuccessful  attempt  to  deliver  will  have  stimulated 
contractions  of  the  uterus,  and  produce  a  condition  of 
partial  spasm,  where  rupture  of  the  uterus  might  readily 
occur. 

Accidents  and  Injuries  Caused  by  Forceps. — In  the  ex- 
perience of  the  writer  cases  have  been  seen  where  the  blade 
has  been  broken  off  and  the  cephalic  portion  left  within  the 
uterus.  The  forceps  has  been  forced  through  the  uterus  into 
the  pelvic  and  peritoneal  cavities.  The  forceps  has  grasped 
a  portion  of  the  cervix  and  torn  it  away,  causing  free  hemor- 


THE    FORCEPS  339 

rhage.  The  forceps  has  also  torn  the  uterus  so  that  after  the 
delivery  of  the  child  and  its  appendages  the  intestine  has  pro- 
lapsed. Traction  by  the  forceps  has  been  so  violent  and  ill- 
directed  that  the  pubic  joint  has  been  separated  and  the  sacro- 
iliac  joints  have  been  strained.  The  child  has  been  killed 
by  fracture  of  the  skull,  and  in  one  case  blindness  resulted 
from  pressure  of  the  forceps  blade  upon  the  eye.  Bruises, 
lacerations  and  wounds  of  the  scalp,  cranial  periosteum  and 
cranial  bones,  lacerations  of  the  membranes  surrounding  the 
brain,  rupture  of  the  middle  meningeal  artery,  followed  by 
hemorrhage,  and  pressure  upon  the  head  producing  dropsy 
of  the  ventricles — have  all  been  observed.  Severe  hemor- 
rhage following  laceration  of  the  cervix,  because  delivery 
was  attempted  before  dilatation  was  complete,  is  not  in- 
frequent. Extensive  lacerations  of  the  cervix,  the  pelvic 
floor  and  perineum,  may  accompany  forceps  delivery. 

With  this  chapter  of  accidents  which  have  been  observed 
in  the  experience  of  one  person,  goes  the  prostrating  effect 
of  hemorrhage,  of  lacerations  of  the  birth  canal,  and  the 
added  complication  of  septic  infection. 

Where  difficult  forceps  operations  are  attempted  in  tene- 
ments and  other  unfavorable  surroundings,  septic  infection 
is  almost  inevitable. 

The  mistake  is  sometimes  made  of  applying  forceps  in 
doubtful  cases  of  disproportion,  with  the  idea  that,  if  the 
head  could  not  be  brought  through  the  birth  canal,  the 
pressure  of  the  forceps  would  virtually  do  a  craniotomy. 
This  is  an  unfortunate  mistake,  for  if  pressure  by  forceps  is 
sufficiently  violent  to  kill  the  child  it  will  fracture  the  cranial 
bones,  and  pieces  of  the  bone  may  be  forced  through  the 
scalp  and  wound  the  mother.  Where  there  is  grave  doubt 
concerning  the  possibility  of  delivery  by  forceps,  it  is  far 
better  to  perform  craniotomy  than  to  persist  in  violent  and 
protracted  efforts  at  forceps  delivery. 

The  Prevention  of  Shock  and  Hemorrhage. — So  soon  as 
the  fetus  has  been  delivered  the  patient  should  receive  a  hy- 
podermatic injection  of  -^  grain  of  strychnia  and  yi^  grain 
of  atropin,  with  one  syringeful  of  an  aseptic  preparation  of 
ergot.  This  will  prevent  relaxation  and  bring  about  the 
prompt  separation  of  the  placenta.  At  the  conclusion  of  the 


340  MANUAL   OF   OBSTETRICS 

operation  this  stimulation  should  be  repeated  hypodermati- 
cally.  After  delivery  the  strychnia  and  ergot  may  be  given 
by  the  mouth  for  a  week  or  ten  days  to  ensure  good  involu- 
tion. 

The  gauze  packing  should  be  removed  in  forty-eight  hours 
and  the  uterus  gently  but  thoroughly  irrigated  with  1  per 
cent,  lysol.  No  further  douching  should  be  employed.  The 
stitches  may  be  cleaned  by  pouring  upon  them  an  antiseptic 
solution  from  a  pitcher. 

The  Care  of  Cases  Having  Severe  Lacerations. — If  labor 
has  been  long  and  exhausting  and  the  conditions  are  unfavor- 
able for  immediate  suture,  the  operator  may  delay  the  clos- 
ure of  lacerations  for  twenty-four  hours.  When  a  patient 
has  fully  reacted  from  labor  she  may  be  anesthetized  with 
ether  and  all  lacerations  repaired.  The  packing  of  the  uterus 
should  not  be  deferred,  however,  but  should  be  done  imme- 
diately. 

In  lacerations  through  the  sphincter  or  into  the  bowel, 
if  the  rectal  tissues  be  extensively  torn  it  may  be  well  to 
inhibit  the  action  of  the  bowels  for  a  few  days  after  delivery 
by  giving  opium.  It  is  usually  better,  however,  to  move  the 
bowels  promptly  with  compound  licorice  powder  in  small,  but 
repeated  doses,  to  secure  the  evacuation  of  thoroughly  soft 
feces. 

The  patient  will  require  the  use  of  the  catheter  for  a  short 
time,  but  this  should  be  discontinued  as  soon  as  possible. 
Before  and  after  micturition  the  parts  should  be  thoroughly 
flushed  with  1  per  cent,  lysol. 

The  Maternal  Mortality  and  Morbidity  of  the  Forceps. — 
This  is  impossible  to  estimate  for  all  classes  of  operators,  be- 
cause so  much  depends  upon  the  skill  and  judgment  of  the 
operator.  In  good  hands,  delivery  by  forceps  has  a  very 
small  maternal  mortality,  and  this  results  from  occasional 
death  by  heart  clot,  exhaustion,  or  infection.  In  the  hands 
of  unskilled  and  dirty  operators  the  mortality  of  difficult 
or  complicated  forceps  deliveries  rises  to  20  and  30  per  cent. 

The  morbidity  following  the  use  of  forceps  depends  upon 
the  skilful  and  judicious  use  of  the  instrument.  Where 
the  head  is  grasped  before  moulding  has  occurred  and  for- 
ceps delivery  is  made,  extensive  laceration  must  result. 


THE    FORCEPS  341 

While  infection  may  !><•  escaped  under  skilful  antiseptic  care, 
the  patient's  recovery  to  health  will  be  retarded. 

The  morbidity  following  the  use  of  forceps  is  greatly  les- 
sened or  increased,  as  lacerations  are  promptly  and  properly 
repaired.  Where  this  work  is  done  thoroughly  and  immedi- 
ately the  morbidity  rate  of  forceps  cases  sinks  to  almost 
nothing.  But  where  this  important  element  is  neglected, 
infection  of  varying  degree  is  common,  and  the  anatomical  re- 
sults are  disastrous. 

The  Effect  of  Forceps  Delivery  upon  the  Child. — It  has 
been  proven  by  careful  observation  that  the  proper  use  of 
forceps  not  only  does  not  add  to  fetal  mortality  and  mor- 
bidity, but  distinctly  prevents  them.  In  delayed  labor  the 
greatest  danger  to  the  fetus  arises  from  birth  pressure,  and 
this  is  removed  by  proper  forceps  delivery.  Where,  how- 
ever, the  forceps  is  applied  to  the  head  before  engagement 
and  moulding  has  been  satisfactorily  accomplished,  or  with- 
out reference  to  the  position  of  the  head,  or  direction  of  the 
pelvic  axis,  injury  to  the  fetus  is  unavoidable.  Such  injury 
consists  in  bruises  upon  the  scalp  and  face,  lacerations  of  the 
soft  parts,  depressions  in  cranial  bones,  bruising  and  wound- 
ing of  the  periosteum,  and  in  some  instances  actual  fracture 
of  the  cranial  bones  and  wounds  of  the  blood-vessels.  The 
less  severe  forms  of  bruises  and  lacerations  of  the  scalp  re- 
quire cleaning  with  boracic  solution.  Depressed  fractures 
of  the  cranial  bones,  if  pronounced  and  over  important  areas, 
should  be  treated  by  immediate  elevation  of  a  bone.  Where 
fracture  occurs  about  the  base  of  the  skull  with  laceration  of 
cerebral  vessels,  treatment  is  unavailing. 

The  effort  is  sometimes  made  to  connect  mental  and 
nervous  diseases  with  injuries  received  by  forceps  during 
birth.  Unless  labor  has  been  unusually  difficult,  and  the 
forceps  has  been  unskilfully  used,  it  is  much  more  likely 
tnat  cerebral  lesions  have  resulted  from  birth  pressure  before 
the  application  of  forceps  and  that  the  instrument  itself  has 
not  caused  the  trouble.  In  some  cases  congenital  mal- 
formations are  present  which  are  accompanied  by  congenital 
lesions  of  the  nervous  system. 

The  Field  for  the  Use  of  Forceps. — With  improvements  in 
obstetric  surgery  and  the  successful  performance  of  Cesarean 


342  MANUAL   OF   OBSTETRICS 

section,  there  is  no  longer  excuse  for  the  improper  use  of  the 
obstetric  forceps.  The  application  of  the  forceps  before 
engagement  and  moulding  should  be  abandoned. 

In  contracted  pelvis  especial  caution  must  be  exercised 
that  impaction  of  the  head  in  the  brim,  with  presentation  of 
the  parietal  bone,  is  not  mistaken  for  normal  engagement  and 
moulding.  Caution  must  also  be  observed  in  cases  where 
there  is  doubt  concerning  delivery  through  the  vagina,  but 
the  forceps  should  not  be  applied,  and  delivery  by  section 
selected,  before  forceps  applications  have  been  made. 

It  is  impossible  to  apply  the  forceps  and  make  tentative 
traction  without  doing  some  injury,  however  slight,  and 
without  introducing  bacteria  from  the  vagina  into  the  cer- 
vix or  uterine  cavity.  Again,  in  some  cases  where  the  child 
is  in  bad  conditionx  and  probably  dying,  if  the  fetus  is  im- 
pacted and  the  position  not  favorable  for  easy  forceps 
delivery,  craniotomy  should  be  selected. 

Some  operators  prefer  to  precede  the  application  of  for- 
ceps in  moderately  contracted  pelves  by  the  application  of 
the  pubiotomy  saw.  With  the  forceps  in  position,  traction  is 
very  carefully  made  with  the  hope  of  securing  descent.  If 
this  fails,  the  pubes  is  severed  without  removing  the  forceps, 
and  the  head  is  delivered  through  the  vagina  by  the  instru- 
ment. 

While  this  method  may  be  successful  in  hospitals  and 
in  skilled  hands,  it  should  not  be  attempted  in  private  houses. 


CHAPTER  XIX 
VERSION 

By  version  is  understood  the  turning  of  the  fetus  in  the 
uterus  so  that  its  long  axis  corresponds  with  the  long  axis  of 
the  birth  canal.  Version  is  of  three  varieties — external, 
combined  and  internal  version. 

External  Version. — By  external  manipulation  the  endeavor 
is  made  to  turn  the  fetus,  situated  transversely  across  the 
pelvis,  so  that  the  head  or  the  breech  may  descend  into  the 
pelvis.  This  operation  is  indicated  in  transverse  positions, 
in  brow  and  parietal  bone  presentations,  and  in  anomalous 
positions  of  the  fetus,  where  spontaneous  descent  into  the 
pelvis  is  impossible. 

To  perform  this  successfully  the  membranes  must  be  un- 
ruptured,  or  have  but  recently  ruptured,  the  uterus  must 
be  relaxed  and  dilatable,  and  the  mother  and  child  must  be 
in  good  condition.  If  the  membranes  have  been  ruptured 
for  some  time,  and  the  amniotic  liquid  has  escaped,  there  is 
danger  of  uterine  rupture,  as  the  uterus  may  contract  tightly 
upon  the  child.  Occasionally  in  multiparse  whose  tissues 
are  greatly  relaxed,  or  primiparse  who  are  ill-developed  and 
relaxed,  the  uterus  is  so  dilatable  that  version  by  this  method 
is  possible. 

To  perform  the  operation  the  position  of  the  fetus  must 
first  be  clearly  outlined  by  palpation  and  auscultation.  As 
a  cold  hand  placed  upon  the  patient's  abdomen  may  excite 
contractions  of  the  abdominal  muscles,  the  hands  of  the 
operator  must  be  thoroughly  warmed.  If  the  patient  is 
excitable  and  nervous,  anesthesia  may  be  necessary.  As 
brief  anesthesia  only  is  required,  chloride  of  ethyl  or  carbon- 
dioxid,  when  available,  may  be  used. 

The  patient  is  placed  upon  a  table  with  the  thighs  and 
legs  flexed  to  relax  the  abdominal  muscles.  The  urinary 

343 


344 


MANUAL    OF    OBSTETRICS 


bladder  should  be  emptied  by  catheter.  The  operator  must 
decide  from  the  location  of  the  fetus  whether  he  proposes  to 
bring  the  breech  or  the  head  to  the  pelvic  brim.  Standing 
with  his  back  toward  the  patient's  head,  or,  if  he  prefers, 
facing  her,  with  both  hands  by  gentle  intermittent  pressure 
and  manipulation,  he  carries  one  end  of  the  fetal  body 
upward,  the  other  downward.  Between  the  manipulations 
he  holds  gently  but  firmly  the  changed  position  which 


Fig.  124. — Version  by  external  manipulation. 

he  has  produced.  When  the  part  selected  is  brought  to 
the  pelvic  brim  he  endeavors  to  secure  its  entrance  into 
the  brim  if  possible  by  subpubic  pressure.  If  the  mem- 
branes are  unruptured  and  the  patient  is  a  multipara,  the 
rupture  of  the  membranes  will  cause  the  uterus  to  con- 
tract upon  the  fetus  and  to  hold  it  in  the  desired  posi- 
tion. If  it  is  not  thought  advisable  to  rupture  the  mem- 
branes a  large  firm  pad  may  be  placed  along  the  patient's 


VERSION  345 

abdomen  against  the  abdominal  surface  of  the  fetus  in  the 
uterus.  A  binder  should  then  be  applied,  with  the  hope  that 
this  pressure  will  prevent  the  fetus  from  resuming  its  former 
abnormal  position. 

External  version  does  not  expose  the  patient  to  the  dan- 
gers of  infection  which  accompany  vaginal  manipulation. 
The  conditions  which  are  necessary  for  its  favorable  per- 
formance are  not  often  present,  but  in  a  few  cases  the  pro- 
cedure is  of  value,  and  may  avoid  the  necessity  of  internal 
version. 

Combined  Version. — By  this  method  several  fingers  of  one 
hand  are  introduced  within  the  vagina  and  cervix  to  press  the 
presenting  part  of  the  fetus  up  and  out  of  the  pelvic  brim, 
while  the  other  hand,  applied  externally,  gradually  turns 
the  fetus  into  such  a  position  that  the  internal  fingers  can 
grasp  a  foot.  This  procedure  is  commonly  known  as  the 
Braxton-Hicks  method. 

The  principal  indication  for  combined  version  is  pla- 
centa praevia.  Occasionally  it  is  employed  to  correct  an  un- 
favorable presentation  and  position,  and  rarely  to  dislodge 
an  impacted  shoulder  and  bring  about  extraction  by  the  feet 
and  breech.  This  method  may  be  employed  in  placenta 
prsevia  in  the  earlier  months  of  gestation  as  well  as  at  term. 

If  the  patient  be  a  multipara  with  dilated  birth  canal,  and 
if  she  be  not  excitable,  this  procedure  may  sometimes  be 
carried  out  without  anesthesia.  If  the  patient  be  a  primi- 
para,  or  if  she  is  sensitive  to  manipulation,  anesthesia  is 
necessary.  Surgical  anesthesia  with  ether  will  be  required, 
while  actual  manipulation  is  performed. 

For  this  operation  the  patient  is  placed  upon  her  back  at 
the  edge  of  a  table  or  bed,  with  the  thighs  and  legs  flexed  and 
supported  by  a  sheet  or  by  assistants.  The  urinary  bladder 
must  be  emptied  thoroughly  by  catheter  and  a  vaginal  irri- 
gation of  1  per  cent,  lysol  given.  The  operator  observes  an- 
tiseptic precautions,  and  if  he  is  accustomed  to  work  with 
rubber  gloves  he  should  use  them.  If  he  has  not  had  ex- 
perience in  the  use  of  gloves  he  should  prepare  the  hands  with 
unusual  caution  and  dispense  with  gloves.  Choosing  which- 
ever hand  he  prefers,  the  hand  is  introduced  slowly  and  grad- 
ually into  the  vagina,  dilating  the  vagina  during  its  intro- 


346  MANUAL   OF   OBSTETRICS 

duction.  It  is  usually  necessary  to  introduce  the  greater 
portion  of  the  hand.  Seeking  the  cervix  two  or  three  fingers 
are  then  introduced,  and  the  head — the  presenting  part — 
is  pushed  up  gently  and  away  from  the  os.  While  this  is 
done  the  external  hand  pushes  the  breech  upward  and  toward 
the  side  opposite  to  that  toward  which  the  internal  fingers 
raise  the  head.  Thus,  if  the  operator  with  the  internal 
fingers  pushes  the  head  upward  and  toward  the  patient's  left 
side  with  the  external  hand,  the  breech  is  carried  upward 
across  and  downward  toward  the  right  side.  As  the  head 
leaves  the  os  the  internal  fingers  are  carried  upward  and  to 
the  right,  and  if  the  membranes  are  unruptured  they  should 
be  torn  asunder.  As  the  breech  passes  toward  the  right  a 
foot  will  prolapse,  and  this  should  be  grasped  by  the  internal 
fingers  and  slowly  and  gently  drawn  downward  bringing  the 
breech  into  the  pelvic  cavity.  The  foot  should  be  brought 
through  the  cervix  and  into  the  vagina,  and  to  it  should  be 
attached  a  noose  of  sterile  gauze  bandage  material. 

The  operation  should  cease  at  this  point,  for  this  method 
is  not  intended  for  the  delivery  of  the  fetus. 

In  central  placenta  prsevia  the  internal  os  being  entirely 
covered  by  placenta,  the  operator  must  enter  the  fetal  sac 
by  tearing  through  the  placental  substance.  This  will  cause 
hemorrhage,  until  the  foot  has  been  reached,  and  the  hem- 
orrhage is  checked  by  the  pressure  of  the  fetus  against  the 
placental  tissue. 

Obviously  the  performance  of  this  operation  is  most  diffi- 
cult in  cases  where  the  membranes  have  long  been  ruptured 
and  the  amniotic  liquid  has  in  large  part  escaped.  It  is 
most  valuable  in  hemorrhage  from  placenta  praevia,  as  it 
controls  the  bleeding  by  using  the  fetal  body  as  a  tampon. 
Its  performance  exposes  the  patient  to  the  danger  of  uterine 
rupture,  hemorrhage  from  separation  of  the  placenta,  and 
infection,  but  it  remains  the  best  method  of  treatment  for 
central  placenta  prsevia,  if  the  patient  cannot  be  transported 
to  hospital  and  given  the  advantage  of  abdominal  section. 
It  must,  however,  be  remembered  that  extraction  is  not  in- 
tended in  the  performance  of  this  operation,  and  that  its 
purpose  is  to  check  hemorrhage  at  the  expense  of  the  fetal 
life. 


VERSION  347 

Internal  Version. — This  operation  is  often  called  internal 
podalic  version  because  ordinarily  the  feet  of  the  child  are 
sought  and  brought  down. 

Indications. — The  indications  for  internal  podalic  version 
are  transverse  position  shoulder  presentation,  brow  and 
parietal  bone  presentation,  prolapse  of  the  umbilical  cord, 
anomalous  position  of  the  head  where  the  forceps  slip  when 
applied  and  forceps  delivery  is  dangerous. 

Prophylactic  version  is  sometimes  performed  in  flat  pelvis 
where  it  is  desired  to  bring  the  fetus  through  with  the  bi- 
frontal  diameter  of  the  fetal  head  in  relation  with  the  short- 
ened antero-posterior  diameter  of  the  pelvic  brim. 

Contraindications. — Internal  version  is  prohibited  where 
the  uterus  is  tightly  contracted  upon  the  fetus,  the  membranes 
having  ruptured  and  the  amniotic  liquid  escaped.  In  such 
cases  the  operation  may  rupture  the  uterus  and  cause  the 
death  of  the  patient. 

It  is  also  contraindicated  in  highly  contracted  pelves,  and 
to  be  successful  the  internal  antero-posterior  diameter  of  the 
pelvic  brim  must  be  not  less  than  9  cm.,  and  it  is  contraindi- 
cated where  the  fetus  is  of  unusual  size  and  development, 
where  a  monstrosity  is  present,  or  where  a  tumor  blocks  the 
birth  canal. 

The  Choice  of  an  Anesthetic. — During  the  performance 
of  internal  version  it  is  desirable  to  relax  the  uterine  muscle 
as  much  as  possible.  To  accomplish  this  the  operator  has 
the  choice  of  carrying  anesthesia  with  ether  to  the  complete 
stage  of  relaxation,  or  of  employing  chloroform  well  diluted 
with  oxygen  or  with  air. 

Position  of  the  Patient. — For  this  operation  the  patient  is 
placed  upon  the  back  on  a  high  bed  or  table,  at  the  edge. 
The  limbs  are  supported  by  a  sheet  or  by  assistants  and  are 
flexed  and  the  knees  rotated  outward.  The  urinary  bladder 
is  emptied  completely  by  catheter,  the  external  parts  thor- 
oughly cleansed  with  antiseptics,  and  a  vaginal  irrigation  of 
1  per  cent,  lysol  is  given. 

The  operator  must  know  the  position  of  the  child  as  ac- 
curately as  possible  by  palpation  and  auscultation.  He 
should  have  in  readiness  the  obstetric  forceps,  instruments 
for  closing  lacerations  and  for  introducing  gauze  packing. 


348  MANUAL    OF    OBSTETRICS 

Antiseptic  precautions  should  be  thoroughly  carried  out. 
Rubber  gloves  should  be  used  and  the  entire  arms  of  the 
operator  covered  with  sterile  material.  Some  prefer  to  use 
for  this  operation  the  long  rubber  gauntlet. 

The  Performance  of  the  Operation. — Having  outlined  the 
fetus  the  operator  introduces  that  hand  which  is  opposite 


Fig.  125. — Introduction  of  the  left  hand  to  grasp  the  anterior  foot  for 
version  (after  Liepmann). 

the  fetal  breech  and  lower  extremities.  The  back  of  the 
hand  is  lubricated  before  it  is  introduced  within  the  vagina, 
the  entire  hand  folded  as  small  as  possible,  and  the  vagina 
gradually  dilated  by  the  hand  as  it  is  introduced.  The  hand 
is  carried  into  the  cervix  and  a  thorough  examination  of  the 
position  of  the  fetus  is  made.  The  external  hand  should 


VERSION  349 

then  by  gentle  pressure  raise  the  fetal  head  from  its  position 
above  the  pelvic  brim.  As  this  is  done  the  internal  hand 
passes  upward  and  seeks  the  legs  and  feet.  If  both  can  be 
identified  the  lower  foot  and  leg  should  be  firmly  grasped,  or 
if  convenient  both  feet  and  legs.  The  operator  must  re- 
member in  all  manipulations  to  turn  the  fetal  back  toward 


Fig.  126. — Bringing  down  the  fetus  by  traction  upon  the  thigh. 

the  pubes,  as  otherwise  difficulty  may  be  experienced  in  de- 
livering the  aftercoming  head.  When  one  or  both  lower  ex- 
tremities have  been  secured,  intermittent  and  gentle  traction 
is  made  downwards  and  backwards  until  the  feet  emerge 
through  the  vulva.  With  the  external  hand  the  head  is 


350 


MANUAL   OF   OBSTETRICS 


pressed  up  until  the  version  is  completed,  and  the  fetus  is 
then  followed  down  by  external  pressure  to  preserve,  if 
possible,  the  flexed  position  of  the  head  and  the  folded  posi- 
tion of  the  arms. 

Extraction. — If  the  operator  decides  not  to  extract  the 
child  the  operation  ceases  when  the  feet  emerge  from  the 
vulva.  The  patient  must  then  be  allowed  to  recover  con- 


Fig.  127. — Extraction  of  the  breech  by  making  traction  in  the  fetal 

groins. 

sciousness,  and  delivery  by  breech  presentation  should  be 
awaited. 

In  most  cases  version  is  followed  by  extraction.  To  per- 
form this  the  uterus  is  stimulated  by  contraction,  by  an 
assistant,  by  massage  and  downward  pressure. 

The  operator,  as  the  feet  descend,  wraps  the  fetus  and 
limbs  of  the  child  in  a  warm  sterile  towel.  This  has  the 


VERSION 


351 


double  purpose  of  preventing  reflex  stimulation  to  respira- 
tory movements  through  contact  with  the  external  air,  and 
affords  the  operator  a  firmer  grasp  upon  the  fetal  body.  Aid- 
ing the  pressure  from  above  and  the  uterine  contractions, 
the  body  of  the  child  is  brought  gently  downward  until  the 
hips  emerge  at  the  vulva.  Grasping  the  feet  and  legs  with 
one  hand,  the  back  being  anterior,  the  fetal  body  is  then  ro- 
tated obliquely  in  the  cervix  and  vagina,  and  the  disengaged 


Fig.  128. — Extraction;  delivering  the  posterior  hip. 

hand  is  passed  upward  over  the  fetal  back  upon  the  posterior 
shoulder.  From  the  point  of  the  shoulder  the  fingers  are 
then  passed,  with  the  palmar  surface  upon  the  humerus, 
down  to  the  elbow,  and  the  arm  carried  gently  downward 
and  across  the  chest  of  the  fetus.  This  manoeuvre  causes 
complete  descent  of  the  arm  and  forearm  and  brings  the 
arm  down  through  the  pelvic  brim.  The  internal  hand  should 


352 


MANUAL    OF    OBSTETRICS 


then  be  removed  and  grasp  the  fetal  legs  with  a  hot  sterile 
towel,  and  the  body  of  the  child  should  be  rotated  in  the 
opposite  oblique  diameter  of  the  birth  canal.  The  other 
hand  of  the  operator  is  then  passed  over  the  fetal  back  to  the 
shoulder  and  the  remaining  arm  brought  downward  and 
across  the  fetal  chest.  This  manoeuvre  completes  the  de- 
scent of  the  arms. 


Fig.  129. — Extracting  the  arm  extended  over  the  head. 

The  Delivery  of  the  Aftercoming  Head. — When  the  arms 
have  been  brought  down,  an  assistant  should  make  firm  pres- 
sure above  the  pubes  downward  and  backward.  Grasping 
the  pelvis  of  the  child,  wrapped  in  a  hot  sterile  towel,  the 
operator  should  make  traction  downward  and  as  nearly  back- 
ward as  possible  until  the  head  is  in  the  pelvic  brim.  Turn- 
ing his  left  forearm  and  hand  with  the  palmar  surface  of  the 

'^vj:  rj- 


VERSION 


353 


hand  uppermost,  the  child's  body  is  allowed  to  rest  astride 
the  forearm  while  the  long  finger  of  the  upturned  hand  is  in- 
serted into  the  child's  mouth.  Gentle  but  firm  traction  is 
made  upon  the  base  of  the  tongue  and  the  lower  jaw.  The 
other  hand  of  the  operator  is  passed  over  the  back  of  the  fetus, 


Fig.  130. — Forceps  to  the  aftereoming  head. 

the  fingers  divided  at  the  neck  and  resting  upon  the  fetal 
shoulders.  With  the  combined  grasp  the  head  is  rotated  into 
one  of  the  oblique  pelvic  diameters,  and  while  external  pres- 
sure is  made  downward  and  backward  the  fetal  head  is 
brought  over  the  pelvic  floor  and  perineum  with  the  two 
23 


354 


MANUAL   OF   OBSTETRICS 


hands  of  the  operator  by  traction  downward  and  backward, 
then  upward  and  forward  beneath  the  pubes. 

So  soon  as  the  child  is  extracted  the  mouth  should  im- 
mediately be  cleansed  with  soft  sterile  linen  and  sterile  solu- 
tion of  boracic  acid.  If  the  cord  is  beating  it  should  not  be 
tied  and  cut,  but  allowed  to  cease  its  pulsations  spontane- 


Fig.  131. — Delivery  of  the  aftercoming  head.  The  fingers  of  the 
obstetrician's  hand  in  the  mouth  of  the  child  astride  his  left  arm,  his 
right  hand  making  suprapubic  pressure. 

ously.  If  the  cord  is  not  beating  it  should  be  tied  and  cut  at 
once.  Delivery  of  the  placenta,  the  irrigation  and  packing 
of  the  uterus,  and  repair  of  lacerations,  should  be  done  as 
has  been  described  in  treating  of  delivery  by  forceps. 

The  Forceps  to  the  Aftercoming  Head. — After  performing 
internal  podalic  version  the  operator  sometimes  finds  that 


VERSION  355 

the  fetal  head  cannot  be  brought  through  the  pelvis  without 
the  exercise  of  undue  force.  In  these  cases  if  possible  the 
head  should  be  rotated  in  one  of  the  oblique  diameters  of  the 
pelvic  brim.  While  an  assistant  raises  the  limbs  and  body 
of  the  child  above  the  pubes  the  operator  introduces  the  ob- 
stetric forceps  obliquely  applying  them  to  the  sides  of  the 
child's  head  and  along  the  forehead.  Axis  traction  should 
then  be  made,  aided  by  suprapubic  pressure,  and  the  head 
thus  extracted. 

The  Delivery  of  the  Child  When  the  Back  is  Posterior.—- 
When  the  operator  is  unable  to  rotate  the  back  of  the  child 
beneath  the  pubes,  especial  care  is  necessary  that  the  chin  is 
not  carried  upward  behind  the  pubes  and  the  head  thus  be- 
come impacted.  The  arms  may  be  brought  down  in  the 
manner  already  described,  and  for  the  extraction  of  the  head 
the  operator  should  endeavor  to  introduce  the  fingers  into 
the  fetal  mouth  and  bring  the  chin  as  nearly  as  possible  with 
the  fetal  neck  and  chest.  Then  by  rotating  the  body  and 
head  in  an  oblique  pelvic  diameter  aided  by  suprapubic  pres- 
sure, it  may  be  effected. 

If  the  forceps  must  be  used  to  the  aftercoming  head  with 
the  back  posterior,  the  forceps  must  be  applied  along  the 
sides  of  the  head  in  an  oblique  diameter.  It  is  essential 
in  these  cases,  whether  delivering  by  the  hands  or  with  for- 
ceps, to  bring  the  chin  behind  the  pubes  and  beneath  the 
pubes,  and  should  the  operator  fail  in  this,  craniotomy  may 
become  necessary. 

Injuries  to  the  Mother  Accompanying  Podalic  Version 
and  Extraction. — In  addition  to  rupture  of  the  uterus,  to 
which  reference  has  been  made,  in  many  extraction  of  the 
fetus  by  the  breech  causes  considerable  laceration  in  the 
cervix,  the  pelvic  floor  and  perineum.  Where  the  operation 
is  necessary  before  full  dilatation  has  occurred,  the  operator 
should  dilate  the  cervix  as  completely  as  possible,  while  the 
patient  is  deeply  anesthetized,  before  he  performs  version. 

Before  attempting  version  the  operator  must  remember 
to  palpate  the  abdomen  to  search  for  the  contraction  ring 
which  marks  the  lower  edge  of  the  upper  segment,  and  to 
ascertain  whether  or  not  the  lower  segment  is  excessively 
distended.  Should  the  uterus  be  in  firm  contraction  with 


356  MANUAL   OF   OBSTETRICS 

the  contraction  ring  evidently  present  and  the  lower  seg- 
ment greatly  distended,  internal  version  should  not  be  at- 
tempted. Delivery  must  be  accomplished  by  embryotomy 
or  section. 

Injuries  to  the  Child  in  Version  and  Extraction. — In  this 
operation  the  fetal  lower  extremities  may  be  injured  where 
the  legs  are  extended  and  sometimes  stretched  upward  in 
front  of  the  child's  body.  In  these  cases  the  bringing  down 
of  the  leg  or  legs  may  be  difficult  and  fracture  or  sprain  may 
result. 

In  bringing  down  the  fetal  arms,  if  pressure  be  wrongly 
made  and  manipulation  is  done  too  hastily,  the  fetal  arm 
may  be  broken.  Such  fracture  usually  occurs  at  the  surgical 
neck  of  the  humerus,  but  it  may  be  found  in  the  shaft  of  the 
bone  and  is  usually  of  the  green-stick  variety.  Where  the 
fetus  is  of  excessive  size  and  must  be  drawn  forcibly  through 
the  pelvic  brim  fracture  of  the  clavicle  may  occur.  When 
bringing  down  the  head  the  mouth  may,  by  undue  pressure, 
be  injured,  and  the  lower  jaw  may  be  fractured  or  dislocated. 

If  there  is  disproportion  between  mother  and  child  and  if 
the  aftercoming  head  be  delivered  rapidly  and  forcibly,  de- 
pression of  one  or  more  cranial  bones,  or  fracture  of  the  par- 
ietal bones  may  result. 

In  contracted  pelvis  where  disproportion  is  too  great  for 
safe  vaginal  delivery  and  where  version  and  extraction  are 
improperly  undertaken,  the  fetal  cranium  may  be  fractured 
by  fracture  of  a  parietal  bone. 

In  the  delivery  of  the  aftercoming  head,  in  almost  all  cases 
the  fetus  is  subjected  to  unusual  danger  through  pressure  of 
the  cervix  upon  the  child's  neck.  Such  pressure  interferes 
with  the  circulation  of  the  fetus  and  causes  involuntary  respi- 
ratory movements,  which  may  result  in  the  inspiration  of  the 
uterine  contents  and  the  development  of  inspiration  pneu- 
monia. 

During  descent  of  the  child's  body  and  its  delivery,  the 
umbilical  cord  may  become  pinched  between  the  fetal  body 
and  the  sides  of  the  pelvis,  and  asphyxia  may  result.  Be- 
cause of  this  occurrence,  version  and  extraction  has  a  con- 
siderable fetal  mortality  and  is  much  more  dangerous  to  the 
fetus  than  delivery  by  section,  or  the  skilful  use  of  the  forceps. 


VERSION  357 

Internal  Podalic  Version  for  Prolapse  of  the  Umbilical 
Cord. — In  this  manipulation  the  prolapsed  portion  of  the 
cord  is  taken  in  the  hand  which  is  to  grasp  the  feet  and  legs 
and  the  cord  is  carried  through  the  cervix  and  well  above 
the  pelvic  brim.  This  will  prevent  pressure  upon  the  cord  as 
the  child's  body  is  brought  down.  The  replacing  of  the 
cord  must  immediately  be  followed  by  version,  as  the  cord 
will  again  prolapse  if  the  fetus  remains  transverse  and  the 
fetal  body  does  not  block  the  pelvis. 

The  Advantages  of  Internal  Version  and  Extraction.— 
The  great  advantage  of  this  obstetric  operation  lies  in  the 
fact  that  it  does  not  require  incision  and  that  it  can  be  car- 
ried out  by  a  skilled  operator  with  but  little  assistance.  A 
reliable  anesthetizer  is  indispensable,  and  with  such  help 
the  obstetrician  may,  if  necessary,  perform  version  and  ex- 
traction alone.  As  these  cases  often  have  lacerations,  the 
operation,  if  possible,  should  be  done  in  hospital,  where  the 
facilities  for  surgical  operations  are  given. 


CHAPTER  XX 
EMBRYOTOMY 

By  embryotomy  is  understood  the  lessening  in  size  of  the 
fetal  body  or  the  removal  of  a  portion  of  the  fetus.  The 
operation  necessarily  destroys  the  life  of  the  child. 

Varieties. — As  the  head  usually  presents,  the  most  fre- 
quent form  of  embryotomy  is  craniotomy.  In  transverse 
positions  with  breech  extraction,  it  is  sometimes  necessary 
to  cut  the  clavicles  and  permit  the  collapse  of  the  shoulders. 
This  is  termed  cleidotomy. 

In  cases  of  abnormal  condition  of  the  fetal  body  it  may  be 
necessary  to  open  the  abdomen  or  chest  and  extract  a  por- 
tion or  all  of  the  viscera.  This  is  termed  evisceration. 

In  transverse  position  shoulder  presentation,  with  the 
uterus  tightly  contracted  upon  the  child's  body,  it  may  be 
necessary  to  sever  the  neck,  performing  decapitation.  Where 
the  shoulder  is  wedged  into  the  pelvis  the  amputation  of  the 
prolapsed  arm  at  the  shoulder  may  be  required.  In  cases  of 
unusual  difficulty  the  operator  may  be  obliged  to  bring  away 
the  fetus  in  pieces  as  best  he  can. 

Craniotomy. — By  craniotomy  we  understand  the  lessening 
in  size  of  the  fetal  head,  accomplished  by  opening  the  head, 
allowing  its  contents  to  escape,  collapsing  it  by  the  pressure 
of  the  pelvis,  or  crushing  the  head  by  an  instrument  prepared 
for  the  purpose.  When  the  base  of  the  cranium  is  crushed 
the  operation  is  called  basiotripsy. 

Indications. — The  indications  for  craniotomy  are  an  un- 
favorable position  and  presentation  of  the  fetal  head,  the 
child  being  dead  or  dying,  and  the  mother's  condition  such 
that  vaginal  delivery  is  indicated.  Craniotomy  may  also 
be  performed  upon  the  dead  child,  the  head  presenting  in 
cases  of  moderately  contracted  pelvis. 

Where  other  efforts  fail  to  deliver  the  aftercoming  head  in 
version  and  extraction,  craniotomy  may  become  necessary. 

358 


EMBRYOTOMY 


359 


Where  the  child  is  dead  and  impacted  in  the  pelvis,  if  in  the 
judgment  of  the  operator  the  head  should  be  lessened  in  size 
to  avoid  injury  to  the  mother,  craniotomy  is  the  operation  of 
choice. 

Craniotomy,  Cranioclasis,  Cephalo-tripsy. — Craniotomy 
means  simply  the  cutting,  piercing  or  opening  of  the  fetal 
cranium.  This  does  not  lessen  the  size  of  the  head.  For 
extraction,  craniotomy  must  be  followed  by  cranioclasis  or 
cephalo-tripsy. 


Fig.  132. — The  application  of  the  cranipclast  to  the  perforated  head 
for  delivery  (after  Liepmann). 


By  cranioclasis  is  meant  the  collapse  of  the  head  after  it 
has  been  pierced  and  emptied  by  drawing  the  head  with  the 
cranioclast  through  the  pelvic  brim  and  cavity.  The  pres- 
sure of  the  pelvis  upon  the  empty  head  causes  it  to  collapse 
and  lessens  its  diameter. 

By  cephalo-tripsy  the  crushing  of  the  head  is  understood. 
This  is  usually  preceded  by  preparation  for  craniotomy,  but 
cephalo-tripsy  may  be  done  upon  the  unopened  head.  Pres- 
sure is  exerted  by  strong  serrated  forceps  especially  designed 
for  the  purpose. 


360  MANUAL    OF   OBSTETRICS 

Technique  of  Craniotomy,  Cranioclasis,  and  Cephalo- 
tripsy. — These  operations  are  frequently  performed  in  cases 
where  the  mother  has  been  long  neglected  in  labor,  where  her 
tissues  are  bruised  and  swollen,  and  where  infection  may  al- 
ready be  present.  For  these  reasons,  these  cases  must  often 
be  considered  as  infected,  and  the  operator  and  assistant 
should  take  especial  precautions  to  avoid  becoming  infected 
during  the  operation. 

The  patient  is  placed  in  the  dorsal  position  upon  a  suitable 
table,  the  limbs  supported  by  assistants  or  by  a  sheet,  and 
thorough  antiseptic  precautions  are  carried  out.  The  blad- 
der must  be  completely  emptied  by  catheter.  The  operator, 
with  gloved  hand,  palpates  the  head  and  the  pelvis,  and  ex- 
actly determines  the  position  of  the  head.  If  possible,  the 
head  should  be  opened  through  the  parietal  bone,  as  this 
gives  a  firm  point  for  operation  and  results  in  the  best  col- 
lapse of  the  head.  When  the  position  of  the  head  has  been 
ascertained,  an  assistant,  by  suprapubic  pressure,  should 
keep  the  head  firmly  at  the  pelvic  brim.  Using  the  fingers  of 
one  hand  as  a  guard,  the  operator  may  then  open  the  head 
through  the  parietal  bone  by  the  simple  perforator,  a  pair 
of  strong  pointed  scissors  designed  for  the  purpose,  or  he 
may  trephine  through  the  parietal  bone  with  Brauns'  obstet- 
ric trephine.  In  doing  this,  care  must  be  taken  to  hold  the 
trephine  firmly  against  the  cranium,  as  otherwise  it  might 
slip  and  injure  the  mother.  If  the  scalp  is  greatly  swollen 
it  may  be  necessary  to  cut  through  it  down  to  the  bone  before 
applying  the  trephine.  When  the  button  of  bone  has  been 
removed,  the  membranes  at  the  brain  should  be  torn  open  and 
a  large  dull-edged  spoon  curette  introduced,  and  as  much  of 
the  brain  as  possible  should  be  brought  away.  Through  the 
curette  the  cranial  cavity  may  be  irrigated  with  salt  solution, 
or  lysol  1  per  cent.  The  internal  blade  of  the  cranioclast 
is  then  passed  through  the  trephine  opening,  and  the  external 
blade  adjusted  upon  the  cranium,  care  being  taken  to  carry 
the  blades  down  to  the  base  of  the  skull  to  secure  a  firm  grasp. 
The  blades  are  then  closed  and  securely  fastened  by  a  bind- 
ing screw  at  their  external  extremity.  Traction  is  then 
made  in  the  axis  of  the  pelvis,  and  the  head  slowly  and  grad- 
ually brought  through  the  pelvis  and  delivered.  During 


EMBRYOTOMY  361 

this  procedure  the  pressure  of  the  pelvic  walls  will  cause  the 
head  to  collapse  and  it  will  emerge  greatly  elongated,  with 
the  cranioclast  at  the  apex  of  its  pyramidal  form. 

If  the  head  be  unusually  hard  and  its  bones  resisting,  it 
may  be  necessary  after  performing  craniotomy,  to  crush  the 
head  before  delivery.  For  this  purpose  the  blades  of  the 
cephalotribe  are  inserted  along  the  sides  of  the  pelvis  and 
the  head  grasped  without  regard  to  its  position.  By  a  power- 
ful compression  screw  the  blades  of  the  cephalotribe  are 


Fig.    133. — Perforating  the  cranium  through  a  parietal  bone   (after 

Liepmann). 

brought  together  with  the  head  in  its  grasp,  and  the  head  is 
crushed.  Its  extraction  follows  in  the  same  manner  as  in 
forceps  operations. 

The  Basiotribe. — Various  instruments  have  been  devised 
by  which  the  head  can  be  pierced  and  the  external  blades  of 
the  basiotribe  carried  at  once  to  the  base  of  the  cranium, 
the  head  crushed  and  extracted  in  the  grasp  of  the  basiotribe, 
with  the  perforator  still  within  the  cranium.  Such  instru- 
ments have  a  central  stem  or  perforator,  with  such  a  lock 


362  MANUAL   OF   OBSTETRICS 

that  the  two  blades  in  locking  include  the  perforator.  In 
the  use  of  these  instruments  no  attempt  is  made  at  cranio- 
clasis,  nor  is  the  cranium  emptied  befo_re  extraction.  Dur- 
ing extraction  the  brain  matter  is  usually  forced  out  through 
the  opening  made  by  the  perforator. 

Craniotomy  upon  the  Aftercoming  Head. — When  the  after- 
coming  head  cannot  be  delivered  in  the  usual  manner  and  cran- 
iotomy  is  indicated,  some  difficulty  may  be  found  in  securing 
a  suitable  point  of  approach  in  the  fetal  head.  If  the  chin 
be  anterior  it  may  be  necessary  to  enter  the  head  beneath  the 
chin,  passing  the  perforator  upward  through  the  mouth  into 
the  base  of  the  brain.  In  some  cases  perforation  is  done  near 
the  junction  of  the  frontal  and  parietal  bones.  Where  the 
mouth  can  be  reached  it  may  be  necessary  to  open  the  cran- 
ium through  the  roof  of  the  mouth.  In  some  cases  where 
the  breech  has  been  born,  craniotomy  is  best  performed  by 
opening  the  head  beneath  the  occiput. 

The  Child  hi  Craniotomy. — Some  patients  have  religious 
views  concerning  the  baptism  of  the  newborn  child,  in  cases 
where  its  life  is  lost  or  in  danger.  If  the  necessity  arises  for 
doing  craniotomy  upon  a  living  child  the  opportunity  must 
be  given  to  have  the  rite  of  baptism  administered,  if  desired, 
so  soon  as  the  child's  scalp  becomes  visible  during  delivery. 

Craniotomy  is  always  a  distressing  operation,  and  every 
precaution  should  be  taken  that  the  mother  does  not  see  the 
child,  nor  that  it  is  seen  by  any  except  the  father  or  some 
responsible  relative.  Exaggerated  stories  of  its  condition 
may  greatly  depress  the  mother. 

The  Dangers  of  Craniotomy  for  the  Mother. — Craniotomy 
exposes  the  mother  to  the  dangers  of  wounds  and  lacerations 
produced  by  the  slipping  of  the  perforator  or  trephine,  or  the 
pinching  and  tearing  of  tissue  by  the  cranioclast  or  cephalo- 
tribe.  The  ignorant  and  careless  performance  of  the  opera- 
tion has  torn  the  uterus,  and  has  even  opened  the  intestine, 
which  prolapsed.  Where  the  operation  is  unskilfully  per- 
formed, the  edges  of  broken  or  crushed  cranial  bone  may 
pierce  the  fetal  scalp  and  wound  and  lacerate  the  mother. 
As  many  of  these  patients  are  exhausted  and  shocked  at  the 
time  of  operation,  relaxation  and  post-partum  hemorrhage 
may  follow. 


EMBRYOTOMY 


363 


Embryotomy  other  than  Craniotomy. — For  cleidotomy  and 
other  varieties  of  embryotomy,  long  blunt-pointed  scissors 
strong  enough  to  sever  the  fetal  bones,  are  required.  In 
cleidotomy,  while  the  fingers  of  one  hand  act  as  a  guard,  the 
blunt-pointed  scissors  are  pressed  against  the  clavicle  firmly, 
and  the  skin  and  bone  severed  at  the  same  time.  Amputa- 
tion is  performed  in  a  similar  manner,  and  the  opening  of 
the  chest  and  abdomen  are  done  in  this  way.  In  addition 
to  the  scissors  the  operator  may  often  be  greatly  helped  by 
long  clamps,  such  as  are  often  used  in  vaginal  or  abdominal 


Fig.  134. — Decapitation  with  the  blunt  hook. 

hysterectomy.     As  these  instruments  have  a  firm  grasp  they 
may  be  used  for  bringing  away  pieces  of  cranial  bones. 

Decapitation. — To  perform  decapitation,  if  the  fingers  can 
reach  the  neck  the  tissues  should  be  protected  with  one  hand 
while  with  the  other  the  operator  severs  the  neck  with  blunt 
pointed  scissors.  Some  prefer  to  use  a  Brauns'  decapita- 
tion hook,  which  is  passed  over  the  neck,  while  the  side-to- 
side  motion  with  traction  forces  the  hook  through  the  skin 
and  muscles  and  through  the  vertebrae.  In  difficult  cases 
especial  care  is  necessary  in  decapitation  to  prevent  instru- 
ments used  from  wounding  the  mother. 


364  MANUAL   OF   OBSTETRICS 

The  Delivery  of  Fetal  Bones.- — In  neglected  cases  where 
unskilful  efforts  have  been  made  to  perform  craniotomy  the 
obstetrician  may  be  obliged  to  extract  the  head  in  pieces. 
For  this  purpose  strong  serrated  forceps  are  desirable  and 
with  these  and  the  aid  of  the  blunt-pointed  scissors,  delivery 
can  usually  be  effected. 

The  After-treatment  of  Cases  of  Embryotomy. — As  so 
many  of  these  patients  are  infected  at  the  time  of  operation, 
and  as  the  danger  of  uterine  rupture  is  always  present,  after 
extracting  the  child  the  operator  should  deliver  the  placenta 
and  palpate  the  interior  of  the  uterus  to  ascertain  its  condi- 
tion. If  rupture  and  laceration  are  absent,  the  uterus  should 
be  irrigated  with  hot  1  per  cent,  lysol,  and  packed  with  10 
per  cent,  iodoform  gauze.  If  the  condition  of  the  tissues 
justifies  it,  immediate  suture  of  lacerations  should  be  done. 
If  conditions  are  unfavorable,  twenty-four  hours  may  be 
allowed  to  elapse  before  sutures  are  inserted. 

Craniotomy  upon  the  Living  Child. — In  the  present  state 
of  obstetric  surgery  embryotomy  upon  the  living  child,  in 
good  condition,  must  be  abandoned.  If,  however,  the  obste- 
trician be  the  only  physician  available  and  the  parents  abso- 
lutely decline  delivery  of  the  living  child  by  section,  the 
demands  of  humanity  would  oblige  the  obstetrician  to  perform 
craniotomy  upon  the  living  child,  but  under  protest.  Should 
the  patient  be  so  situated  that  she  can  readily  obtain  medical 
aid,  the  obstetrician  would  be  justified  in  withdrawing  from 
the  case. 

If  the  child  has  been  exposed  to  long  and  severe  birth  pres- 
sure, with  the  probability  of  infection,  and  if  craniotomy 
is  demanded  in  the  interests  of  the  mother,  the  indications 
are  clear  for  its  performance. 

Mortality  and  Morbidity. — The  mortality  and  morbidity 
of  embryotomy  in  themselves  are  low.  So  many  of  the  pa- 
tients who  require  these  operations  are  exhausted  and  in- 
fected by  previous  attempts  at  delivery,  or  by  hemorrhage, 
that  considerable  mortality  and  morbidity  result. 


CHAPTER  XXI 
PREVENTION  AND  CLOSURE  OF  LACERATIONS 

Laceration  of  the  birth  canal  in  labor  is  most  apt  to  occur 
where  the  child  is  larger  in  proportion  than  the  mother, 
where  the  mother  is  ill-developed  and  with  abnormal  tissues, 
where  an  unfavorable  position  and  presentation  bring  the 
head  through  the  birth  canal  in  an  unfavorable  position, 
where  undue  haste  is  used  in  delivering,  where  delivery  is 
practised  before  dilatation  is  complete,  and  where  the  mother 
is  not  under  control  at  the  time  of  delivery.  Some  lacera- 
tion is  often  inevitable  in  primiparous  patients  and  its  oc- 
currence reflects  in  no  way  upon  the  attending  obstetrician. 

Prevention  of  Lacerations. — A  knowledge  of  the  relative 
size  of  the  birth  canal  and  of  the  fetus  is  of  great  value  to  the 
obstetrician  in  conducting  labor.  Thus  forewarned  he  can 
avoid  procedures  liable  to  cause  injury  and  by  artificial  dila- 
tation and  skilful  delivery  minimize  lacerations.  The  pre- 
caution to  avoid  delivery  before  the  cervix  is  dilated  is  often 
neglected  and  is  a  frequent  cause  of  laceration.  During  ex- 
pulsion of  the  child  the  mother  should  be  controlled  by  an- 
esthesia, or  if  this  be  not  necessary,  by  avoiding  straining  and 
contraction  of  the  abdominal  muscles.  This  can  often  be 
accomplished  if  the  patient's  mouth  be  kept  widely  open  and 
if  she  breathes  with  the  thorax  only. 

In  primiparse  at  least  laceration  is  less  frequent  if  the  pa- 
tient turns  upon  the  side  at  the  moment  of  delivery.  In 
instrumental  delivery  through  the  vagina,  traction  must  be 
made  in  the  axis  of  the  pelvis  until  the  pelvic  floor  is  reached, 
when  the  line  of  traction  should  be  upward  and  forward. 

The  Support  of  the  Perineum  and  the  Pelvic  Floor. — In 
attempting  this  it  must  be  remembered  that  a  central  tear 
of  the  perineum  extending  only  through  the  mucous  mem- 
brane and  connective  tissue  is  unimportant  and  readily  re- 

365 


366 


MANUAL   OF   OBSTETRICS 


/i 


paired.  On  the  contrary,  lacerations  of  the  pelvic  floor  and 
pelvic  fascia  may  lead  to  prolapse.  The  support  of  the  pel- 
vic floor  should  not  extend  beyond  the  middle  of  the  distance 
between  the  anus  and  the  fourchette.  The  skin  perineum 
should  thus  be  left  through  at  least  half  of  its  extent  without 

support  visible  and  laceration 
should  be  permitted  there  in 
preference  to  deeper  injury. 

It  must  also  be  remembered 
that  if  the  head  be  pressed  too 
strongly  upward  during  deliv- 
ery that  the  occiput  may  lac- 
erate the  anterior  segment  of 
the  pelvic  floor,  causing  hemor- 
rhage from  small  blood  vessels 
near  the  clitoris  and  urethra. 

Diagnosis  of  Lacerations.— 
Lacerations  of  the  genital  tract 
occurring  in  labor  are  diagnos- 
ticated accurately  by  visual  ex- 
amination only.  Clotted  blood 
may  obscure  the  feeling  of  the 
tissues  and  lead  to  error. 

To  thoroughly  examine  the 
genital  tract  the  patient  should 
be  upon  her  back  at  the  edge 
of  a  high  bed  or  table,  and  the 
lower  extremities  flexed  and  ro- 
tated outward.  The  two  lips 
of  the  cervix  should  be  grasped 
by  tenaculum  forceps,  and  with 
a  good  light  directed  upon  the 

parts,  should  be  drawn  downward  until  they  are  plainly  visi- 
ble. If  blood  be  wiped  away  from  the  tissues  the  cervix  can 
be  completely  inspected.  The  difference  between  a  smooth 
tissue  covered  by  normal  membrane  and  the  recently  torn 
parts  is  readily  discernible. 

To  detect  laceration  of  the  pelvic  floor,  the  long  finger  of 
the  gloved  hand  should  be  introduced  into  the  bo\vel  and  the 
pelvic  floor  raised,  while  accumulated  blood  is  sponged  away. 


Fig.  135. — Incomplete  lac- 
eration of  the  pelvic  floor  and 
perineum:  a,  anterior  vaginal 
wall;  b,  posterior  vaginal  wall; 
c,  the  highest  point  in  the  tear 
in  the  left  sulcus;  d,  the  lowest 
point  in  the  tear  in  the  left  sul- 
cus; e  and  /,  the  tear  in  the  right 
sulcus;  g,  the  lowest  point  in  the 
tear  in  the  perineum. 


PREVENTION   AND   CLOSURE    OF   LACERATIONS  367 

The  left  side  should  first  be  examined  as  laceration  is  most  fre- 
quent there,  and  if  a  tear  has  occurred  it  becomes  visible. 
Lacerations  of  the  anterior  segment  of  the  pelvic  floor  are 
readily  detected  by  separating  the  labia,  and  sponging.  Per- 
ineal  tears  are  evident  on  inspection,  and  complete  tears  in- 
volving the  bowel  become  plainly  visible  with  sponging. 

Should  hemorrhage  complicate  lacerations,  it  will  suggest 
that  injury  has  occurred  if  a  small  but  constant  stream  of 


Fig.  136. — The  immediate  repair  of  laceration  of  the  left  side  of  the 

cervix. 

bright  blood  issues  from  the  vagina  while  the  uterus  remains 
firmly  contracted. 

The  Treatment  of  Lacerations.— Obstetricians  differ  some- 
what in  opinion  concerning  the  advisability  of  closing 
immediately  all  lacerations  of  the  cervix.  All  are  agreed  in 
advising  that,  where  cervical  lacerations  are  sufficiently  ex- 
tensive as  to  cause  hemorrhage,  such  should  immediately 


368  MANUAL    OF   OBSTETRICS 

be  closed  by  suture.  The  writer's  experience  is  in  favor  of 
closing  all  cervical  lacerations  which  are  more  than  a  quarter 
of  an  inch  in  extent. 

To  accomplish  this  the  two  lips  of  the  cervix  are  grasped 
with  tenaculum  forceps,  the  cervix  drawn  downward  and 
then  strongly  toward  the  right  side.  When  the  left  labium 
is  drawn  outward  and  the  tissues  are  sponged,  the  laceration 
of  the  left  side  of  the  cervix  becomes  plainly  visible.  This 
should  be  closed  by  stitches  of  chromicized  No.  2  catgut,  in- 
serted with  a  curved  needle,  especial  care  being  exercised 
in  introducing  the  first  and  highest  stitch.  If  the  laceration 
is  extensive  it  may  be  difficult  to  reach  the  beginning  of  the 
laceration,  but  as  this  stitch  is  the  most  important  of  all  it 
must  be  correctly  placed.  Stitches  are  inserted  at  intervals 
of  a  quarter  of  an  inch  until  the  laceration  is  closed  almost  to 
the  external  os.  The  cervix  is  then  drawn  toward  the  left 
side,  the  right  labium  opened,  and  the  laceration  upon  the 
right  side  closed  in  the  same  manner.  Should  a  cervical 
tear  extend  upward  to  and  through  the  vaginal  junction  it 
can  rarely  be  successfully  closed  by  suture.  As  much  as 
possible  of  the  laceration  should  be  brought  together,  and 
oozing  from  the  remainder  controlled  by  intrauterine  tam- 
poning with  gauze  and  the  vaginal  tampon. 

Lacerations  of  the  Pelvic  Floor. — When  these  have  been 
exposed  in  the  manner  described,  the  more  extensive  lacera- 
tions should  first  be  sutured.  Especial  care  must  be  taken  to 
close  accurately  the  highest  point  of  the  laceration.  In- 
terrupted stitches  of  No.  2  chromicized  catgut  are  placed  at 
half-inch  intervals,  the  curved  needle  going  sufficiently  deep 
to  bring  together  not  only  the  mucous  membrane  of  the  vag- 
ina but  the  connective  tissue  and  fascia  beneath  it.  When 
the  deeper  portions  of  the  lacerations  of  the  posterior  seg- 
ment of  the  pelvic  floor  have  been  closed  it  is  well  to  bring 
together  the  torn  edges  of  the  perineum,  for  if  this  precau- 
tion be  not  taken  the  suture  of  the  pelvic  floor  may  be  car- 
ried too  far  down  upon  the  posterior  vaginal  wall,  and  the 
vaginal  wall  will  be  drawn  downward  instead  of  being  raised 
upward  and  backward. 

The  Closure  of  Perineal  Lacerations. — The  sphincter  of 
the  bowel  should  first  be  examined  if  laceration  has  extended 


PREVENTION    AND    CLOSURE    OF   LACERATIONS 


369 


to  tins  point.  If  it  has  been  torn,  one  or  two  buried  sutures 
of  fine  catgut  or  fine  silk  should  be  inserted  through  the  fascia 
and  muscle,  bringing  the  muscles  separately,  completely  to- 
gether. If  the  tear  is  deep,  a  line  of  buried  stitches  of  fine 
catgut  should  bring  together  the  deeper  connective  tissue  and 
fascia.  The  skin  perineum  should  be  closed  from  the  anus 
upward  by  interrupted  stitches  of  silkworm  gut,  not  drawn 
so  tightly  as  to  make  tension.  When  the  skin  perineum  has 
been  brought  together,  the  re- 
mainder of  the  lacerations  of 
the  pelvic  floor  are  readily 
closed  by  interrupted  stitches 
of  catgut. 

Lacerations  of  the  Anterior 
Segment  of  the  Pelvic  Floor. — 
These  are  detected  by  spong- 
ing the  tissues  about  the  ure- 
thra and  the  base  of  the  clitoris. 
These  lacerations  are  longitud- 
inal, varying  in  length,  and 
often  cause  considerable  bleed- 
ing. They  should  be  closed 
by  interrupted  stitches  of  fine 
chromicized  catgut. 

Care  must  be  taken  not  to 
enter  the  urethra  with  the 
needle  if  the  lacerations  are 
deep.  If  the  lacerations  are 
extensive  and  vessels  have 
been  opened,  it  is  well  to  tie 
these  separately  with  fine  cat- 
gut or  fine  silk. 

The  Closure  of  Complete  Lacerations  of  the  Perineum 
and  Pelvic  Floor. — The  complete  must  be  converted  into  the 
incomplete  laceration  by  bringing  together  the  mucous  mem- 
brane of  the  bowel  and  the  torn  ends  of  the  sphincter  muscle 
by  continuous  sutures  of  fine  catgut  or  fine  silk.  It  is  well  to 
terminate  the  suture  of  the  bowel  at  the  sphincter  and  to 
use  separate  and  interrupted  stitches  to  unite  the  muscle. 
When  this  has  been  accomplished,  the  remainder  of  the 
24 


Fig.  137.— Closing  the 
bowel  in  complete  tear  of  the 
pelvic  floor  and  perineum. 


370  MANUAL   OF   OBSTETRICS 

laceration  is  brought  together  in  the  manner  previously 
described. 

The  Closure  of  Episiotomy  Wounds. — It  is  sometimes  ex- 
pedient, in  cases  where  considerable  disproportion  exists 
between  mother  and  child,  to  make  one  or  more  incisions 
downward  and  outward  through  the  labium  and  connective 
tissue  at  the  junction  of  the  lower  and  upper  two-thirds 
of  the  lateral  surface  of  the  opening  at  the  birth  canal. 
These  incisions  allow  the  anterior  segment  of  the  pelvic 
floor  to  retract  upward  and  the  posterior  segment  to  retract 
downward,  thus  preventing  severe  central  lacerations.  After 
delivery  these  surfaces  are  to  be  closed  by  two  lines  of  suture 
— the  inner  brings  together  the  mucous  membrane  of  the 
vagina,  and  the  submucous  connective  tissue;  the  outer 
line  of  suture  at  right  angles  to  the  first,  unites  the  skin  and 
subcutaneous  tissue.  For  the  inner  suture  catgut  is  pref- 
erable, and  for  the  outer  silkworm  gut. 

The  Aseptic  Care  of  Lacerated  Surfaces/ — Cases  which 
have  had  suture  should  be  taken  care  of  by  pouring  1  per 
cent,  lysol  or  sterile  salt  solution  from  a  pitcher  over  the  parts 
after  each  micturition  or  defecation  and  whenever  the  vulvar 
dressing  has  become  stained  and  has  been  removed.  Su- 
tured surfaces  should  not  be  rubbed  with  cotton  sponges,  nor 
touched,  nor  handled.  If  the  patient  must  be  catheterized, 
especial  care  must  be  taken  to  clean  the  orifice  of  the  urethra 
before  and  after  the  catheter  is  used. 

If  lacerated  sutured  surfaces  heal  properly  there  will  be 
little  redness  or  swelling,  pus  wiH  be  absent,  and  union  will  be 
by  first  intention.  Should  these  surfaces  become  infected 
they  will  be  red  and  swollen,  and  pus  will  exude  from  the 
edges.  In  this  event,  stitches  must  be  at  once  removed,  the 
wounds  allowed  to  gape  open,  and  freely  flushed  with  an 
antiseptic  solution.  Healing  must  occur  by  granulation. 

The  Secondary  Repair  of  Lacerations. — If  the  patient's 
condition  makes  it  impossible  to  repair  lacerations  imme- 
diately after  their  reception,  a  delay  of  twenty-four  or  thirty- 
six  hours  may  enable  the  patient  to  recover  from  labor,  and 
may  give  the  obstetrician  better  facilities  for  operation. 
While  a  longer  delay  than  this  is  practised  and  recommended 
by  some,  it  has  not  been  accepted  by  the  majority  of  ob- 


PREVENTION   AND    CLOSURE    OF   LACERATIONS  371 

stetricians.  Secondary  operations  for  the  repair  of  the  birth 
canal  should  not  be  undertaken  while  the  mother  is  nursing 
her  child.  Ample  time  must  be  given  for  complete  recovery 
from  labor  and  for  involution  to  take  place. 

The  principles  upon  which  secondary  operations  are  based 
are  the  denuding  of  torn  surfaces  until  they  resemble  as 
closely  as  possible  the  original  laceration  and  the  bringing 
together  of  these  surfaces  by  suture.  While  absorption  and 
atrophy  or  contraction  of  the  parts  occur,  it  may  be  neces- 
sary to  liberate  contracted  tissue  by  incisions,  making  flaps  to 
restore  the  tissue  lost  by  absorption  after  the  original  lacera- 
tion. 

The  Removal  of  the  Stitches. — Silkworm  gut  stitches 
placed  in  the  skin  perineum  are  ordinarily  removed  by  the 
tenth  day.  Catgut  stitches  do  not  often  require  removal. 
Chromicized  catgut  occasionally  fails  to  be  absorbed  and 
if  its  presence  causes  annoyance,  such  stitches  may  be  re- 
moved two  weeks  after  labor.  To  remove  stitches  suc- 
cessfully, a  strong  light  is  indispensable,  and  scissors  curved 
upon  the  flat,  are  required.  If  the  stitches  have  become 
partially  buried,  a  grooved  director  may  be  slipped  through 
the  stitch,  and  the  blade  of  the  scissors  may  cut  upon  the 
director. 

Repeated  Lacerations. — Some  patients  who  have  sus- 
tained lacerations  in  the  first  labor,  in  subsequent  parturi- 
tion tear  through  the  scar  of  the  original  laceration.  Such 
tears  are  rarely  extensive  and  should  be  promptly  repaired. 


CHAPTER  XXII 

INJURY  TO  THE  BONY  PELVIS  OCCURRING 
DURING  LABOR 

In  cases  of  marked  disproportion  between  mother  and 
child,  with  forcible  delivery  through  the  vagina,  the  sacro- 
iliac  joints  may  be  severely  strained,  or  the  pubic  joint  may 
be  forcibly  separated.  The  left  sacro-iliac  joint  is  most  fre- 
quently involved,  and  the  diagnosis  of  this  condition  is  made 
by  pain  over  the  joint  when  the  patient  turns  in  bed,  or  upon 
walking  or  making  certain  motions,  as  stooping  and  raising. 

On  vaginal  examination  pain  may  be  felt  upon  firm  pres- 
sure at  the  side  of  the  pelvis.  If,  while  the  patient  is  lying 
upon  her  back,  the  lower  extremities  be  flexed  completely 
and  rotated  forcibly  inward  and  outward,  pain  will  be  felt 
in  the  sacro-iliac  region. 

The  treatment  of  this  condition  consists  in  rest  and  in 
wearing  a  firm  retentive  belt.  If  the  patient  is  gouty  or  rheu- 
matic, suitable  medication  is  indicated.  When  the  pubic 
joint  is  forcibly  separated  during  labor  the  two  halves  of  the 
pelvis  move  with  considerable  pain.  The  condition  is  diag- 
nosticated by  introducing  the  fingers  within  the  vagina  and 
detecting  motion  of  the  two  halves  of  the  pubic  bone  as  the 
thighs  are  flexed  and  rotated.  A  firm  belt,  taking  its  centre 
of  pressure  over  the  trochanters,  is  indicated  for  this  condition. 

Injuries  to  the  Coccyx  Occurring  During  Labor. — Where 
the  child  is  excessive  in  size,  or  where  during  forceps  delivery 
the  occiput  is  carried  strongly  backward  the  sacro-coccygeal 
joint  may  be  strained,  or  the  coccyx  may  be  fractured. 

This  condition  is  diagnosticated  by  pain  upon  introducing 
the  finger  within  the  vagina  or  rectum  and  making  pressure. 
If  the  patient  be  turned  upon  her  side,  and  the  fingers  car- 
ried down  over  the  sacrum  upon  the  coccyx,  the  injury  can 
be  detected.  Should  pain  in  the  coccyx  persist  after  labor, 

the  bone  should  be  removed. 

372 


CHAPTER  XXIII 
THE  INDUCTION  OF  LABOR 

The  induction  of  labor  is  indicated  where  pregnancy  is 
unduly  prolonged,  the  pelvis  being  sufficiently  large  to  per- 
mit the  birth  of  an  average  or  viable  child,  or  where  some  con- 
dition arises  that  renders  the  continuation  of  pregnancy  un- 
favorable for  the  life  and  health  of  mother  and  child.  Such 
a  condition,  however,  must  not  be  critical,  for  the  induction 
of  labor  is  a  slow  process,  and  if  no  time  is  to  be  lost  it  can- 
not be  selected. 

As  the  name  indicates,  the  induction  of  labor  is  the  arti- 
ficial establishment  of  spontaneous  delivery.  It  must  be 
effected  by  exciting  uterine  contractions. 

While  various  methods  have  been  tried  and  discarded, 
the  introduction  of  sterile  bougies  with  or  without  the  ac- 
companiment of  sterile  dilating  bags  passed  within  the  cer- 
vix, is  the  method  most  widely  practised.  In  some  cases, 
instead  of  bougies  and  bags,  strips  of  gauze  are  inserted 
through  the  cervix  to  bring  about  uterine  contractions  and 
dilatation.  In  multiparous  patients  with  soft  cervix  and 
partial  dilatation,  the  rupture  of  the  membranes  is  some- 
times the  method  of  choice. 

Technic. — In  induced  labor  the  obstetrician  must  first 
ascertain  accurately  that  the  pelvis  is  sufficiently  large  to 
permit  the  passage  of  the  child.  It  is  commonly  believed 
that,  unless  the  antero-posterior  internal  diameter  is  8  cm., 
the  induction  of  labor,  with  the  hope  of  securing  a  viable 
child,  should  not  be  chosen. 

As  regards  the  period  of  gestation,  operators  aim  to  in- 
duce labor  not  earlier  than  the  thirty-second  week  nor  later 
than  the  thirty-sixth  week  of  gestation. 

The  clinical  test  of  pressing  the  head  into  the  pelvic  brim 
by  pressure  made  with  the  external  hand  while  the  internal 

373 


374  MANUAL   OF   OBSTETRICS 

hand  notes  the  descent  of  the  head,  is  a  method  of  proven 
value. 

The  patient  is  prepared  for  the  induction  of  labor  by 
thorough  emptying  of  the  intestine,  complete  emptying  of 
the  urinary  bladder,  and  irrigation  of  the  vagina  with  1  per 
cent,  lysol.  The  external  parts  are  antiseptically  prepared. 
If  the  patient  be  a  primipara,  and  sensitive,  anesthesia  is  of 
great  assistance.  With  the  patient  in  the  dorsal  position, 
at  the  edge  of  a  bed  or  table,  the  fingers  of  the  gloved  left 
hand  are  introduced  within  the  vagina  and  the  effort  made  to 
gently  introduce  one  finger  through  the  cervix.  If  this  can 
be  done  the  finger  is  swept  around  the  internal  os,  detaching 
the  membranes  from  the  surface  of  the  uterus  as  widely  as 
possible.  Care  should  be  taken  not  to  rupture  the  mem- 
branes. If  the  finger  cannot  be  passed  through  the  cervix, 
the  cervix  should  be  drawn  down  by  tenaculum  forceps  and 
very  gently  dilated  with  solid  dilators,  until  the  finger  can 
be  introduced. 

One  or  more  blunt-pointed  sterile  bougies  of  large  size 
should  be  introduced,  and  passed  gently  in  the  direction  of 
least  resistance.  They  should  pass  between  the  membranes 
and  the  wall  of  the  uterus  until  but  an  inch  protrudes  from 
the  cervix.  If  more  than  one  can  be  introduced,  it  is  well  to 
do  so.  These  are  retained  in  place  by  tamponing  the  vagina 
with  moderate  firmness  with  sterile  gauze  or  10  per  cent,  iodo- 
form  gauze. 

It  is  often  convenient  to  begin  the  induction  of  labor  at 
the  patient's  usual  bed-time.  If  she  be  given  a  simple  seda- 
tive medicine  she  will  often  sleep  through  the  night,  the  cer- 
vix will  soften  and  dilate,  and  actual  labor  pains  will  develop 
during  the  following  day.  If  it  is  desired  to  bring  on  labor 
as  promptly  as  possible  and  the  cervix  is  dilated  or  dilatable, 
the  dilating  bag  may  be  introduced  in  place  of  bougies.  This 
should  be  distended  to  nearly  its  capacity  and  retained  in 
place  by  a  vaginal  packing  of  iodoform  gauze. 

Unless  active  pains  develop,  the  patient  should  not  be  dis- 
turbed until  ten  to  twelve  hours  afterward,  and  the  bougies 
or  bags  should  be  removed,  the  vagina  irrigated  with  1  per 
cent,  lysol,  and  a  careful  but  gentle  examination  made. 
The  cervix  will  be  found  softened  and  somewhat  dilated 


THE   INDUCTION    OF   LABOR  375 

and  a  greater  number  of  bougies,  or  a  larger  bag  may  be 
inserted. 

During  the  day  the  patient  should  take  liquid  food  only, 
should  remain  in  bed,  and  care  should  be  taken  that  the 
urinary  bladder  is  frequently  emptied.  Should  active  pains 
begin  it  is  well  to  remove  the  bougies  to  avoid  rupture  of 
the  membranes.  If  labor  comes  on  slowly  the  bougies  should 
be  removed  in  the  evening,  and  more  inserted,  and  the  pa- 
tient allowed  to  remain  undisturbed  during  the  second  night. 
On  the  day  following,  the  cervix  will  usually  be  found  suf- 
ficiently dilated  to  permit  the  introduction  of  a  good-sized 
bag,  which  should  be  distended  with  antiseptic  fluid  and  left 
within  the  cervix.  If  active  pains  develop  the  bougies 
should  be  removed.  The  bag  should  be  completely  dis- 
tended, and  if  possible  should  be  expelled  or  drawn  through 
the  cervix  distended  to  its  full  capacity. 

The  Length  of  Time  Required  for  the  Induction  of  Labor. — 
Induced  labor  varies  greatly  in  duration.  Occasionally 
labor  develops  actively  within  a  few  hours.  In  insane  pa- 
tients it  is  almost  impossible  to  induce  labor,  as  the  presence 
of  bougies  or  bags  often  do  not  excite  uterine  contractions. 
The  induction  of  labor  is  a  comparatively  slow  and  uncer- 
tain process,  and  the  pressure  of  dilating  bags  may  cause  the 
patient  severe  suffering.  Some  prefer  not  to.  use  bags,  but 
to  rely  exclusively  upon  bougies  and  to  continue  the  induc- 
tion of  labor  by  these  means  until  the  cervix  is  three-fourths 
dilated.  The  dilatation  may  then  be  completed  by  the  hand 
and  the  membranes  ruptured,  when  active  labor  will  follow. 

The  Maternal  Dangers  of  Induced  Labor. — Repeated 
manipulation  may  cause  septic  infection,  the  introduction 
of  bougies  may  disturb  the  placenta,  causing  hemorrhage, 
bags  may  burst  and  discharge  their  contents  within  the 
uterus,  the  presence  of  the  bag  may  disturb  a  favorable 
presentation  of  the  head,  converting  it  into  an  unfavorable, 
and  the  patient  may  become  exhausted  by  nagging  and 
inefficient  pains  without  the  development  of  normal  uterine 
contractions. 

Under  strict  antisepsis,  and  in  skilled  hands,  the  maternal 
mortality  of  induced  labor  is  low.  Its  morbidity  is  relatively 
high  because  dilatation  is  accomplished  through  a  birth  canal 


376  MANUAL    OF   OBSTETRICS 

not  physiologically  prepared  for  labor,  and  hence  consider- 
able laceration  may  occur. 

The  Effect  upon  the  Child  in  Induced  Labor. — The  mor- 
tality of  the  child  in  induced  labor  is  considerable  because 
it  is  delivered  through  an  imperfectly  dilated  birth  canal, 
and  in  many  cases  is  premature.  The  most  common  cause 
of  fetal  death  in  induced  labor  is  birth  pressure. 

The  morbidity  among  children  so  born  is  considerable, 
as  labor  must  frequently  be  terminated  by  forceps  or  ver- 
sion, and  the  premature  child  is  subjected  to  considerable 
force.  In  comparison  with  spontaneous  birth  or  delivery 
by  Cesarean  section,  induced  labor  has  a  high  fetal  mortality 
and  morbidity. 

Forcible  Delivery  (Accouchment  Force). — By  this  is  un- 
derstood the  forcible  dilatation  of  the  cervix  followed  by 
immediate  extraction  of  the  fetus.  This  procedure  was  for- 
merly accomplished  by  the  hand,  by  dilating  bags,  or  by 
metal  dilators,  of  which  Bossi's  is  most  typical.  Since  the 
advances  in  obstetric  surgery  have  developed  Cesarean  sec- 
tion, this  method  of  delivery  has  been  abandoned  by  experi- 
enced obstetricians.  Injuries  to  the  birth  canal,  caused  by 
such  rapid  dilatation  and  extraction,  accompanied  by  hem- 
orrhage and  septic  infection,  gave  results  far  inferior  to  those 
obtained  by  better  methods. 

The  Complete  Dilatation  of  the  Birth  Canal  by  Bags. — 
During  the  latter  part  of  induced  labor  the  obstetrician  may 
desire  to  dilate  not  only  the  cervix  but  the  pelvic  floor  and 
vagina  as  well.  To  accomplish  this  the  double  bag  of  Pom- 
meroy  has  been  devised.  Of  this,  one  portion  is  inserted 
within  the  cervix  and  the  remainder  is  allowed  to  remain  in 
the  vagina  upon  the  pelvic  floor.  Both  are  dilated  by  sterile 
fluid  introduced  by  a  piston  syringe.  This  device  is  efficient, 
but  naturally  causes  considerable  pain  to  the  patient. 

Dilatation  by  Bags. — In  selecting  bags  for  dilatation  they 
should  be  tested  before  introduction,  by  a  strong  piston  syr- 
inge, and  some  idea  obtained  of  their  capacity.  For  the 
smaller  sizes  Barnes'  bags  are  useful,  while  for  the  larger  dila- 
tation Voorhees  and  Champetier  de  Ribes,  are  well  adapted. 
These  have  a  flat  base,  and  resemble  while  distended  a  pyra- 
mid. The  bag  is  introduced  empty  and  folded  in  the  grasp 


THE    INDUCTION   OF   LABOR 


377 


of  a  suitable  forceps.  It  is  held  in  position  until  the  fluid 
can  be  forced  into  it  by  a  piston  syringe.  Pressure  can  be 
made  by  the  syringe  until  the  fluid  in  the  bag  begins  to  press 
the  piston  backward.  The  tube  of  the  bag  is  then  closed  by 
a  clamp  forceps,  and  the  forceps  is  brought  up  upon  the  ab- 
dominal .surface  near  the  groin,  and  retained  in  position  by  a 
bandage. 


Fig.  138. — Dilating  the  cervix  in  induced  labor  by  a  dilating  bag. 

A  vulvar  dressing  should  be  worn  during  the  induction  of 
labor. 

To  maintain  and  promote  dilatation,  additional  fluid 
should  be  introduced  into  the  bag  every  half-hour  or  hour, 
until  its  limit  has  been  reached. 

While  most  of  the  bags  in  use  are  of  rubber,  the  de  Ribes' 
bag  is  of  silk,  covered  with  a  smooth  and  impervious  material. 
A  bag  fully  distended  causes  severe  pressure,  and  the  patient 


378  MANUAL   OF   OBSTETRICS 

usually  complains  of  this  bitterly.  In  some  cases  the  bag 
excites  uterine  contractions,  in  others  the  pain  which  it 
causes  inhibits  the  action  of  the  uterus. 

When  neither  bougies  nor  bags  bring  on  labor,  and  partial 
dilatation  has  been  accomplished,  with  some  separation  of 
the  membranes,  all  may  be  removed  and  the  patient  allowed 
to  get  up  and  go  about  her  room.  This  will  frequently  re- 
sult in  the  development  of  active  labor. 

The  Treatment  of  the  Patient  during  Induced  Labor. — 
The  obstetrician  must  be  careful  to  place  no  limit  for  in- 
duced labor.  During  this  time  the  patient  should  take  abun- 
dant liquid  food,  avoiding  milk,  unless  it  is  well  digested  -or  is 
peptonized.  The  urinary  bladder  should  be  frequently  emp- 
tied, and  if  the  bowels  become  distended  a  copious  high  pur- 
gative enema  or  saline  irrigation  should  be  given.  At  night 
the  patient  should  have  sufficient  sedative  medicine  to  in- 
duce a  reasonable  amount  of  sleep.  Efforts  should  be  made 
to  divert  her  attention  from  her  suffering  and  to  encourage 
her. 

Scrupulous  care  must  be  taken,  and  antiseptic  precautions 
also,  to  avoid  infection.  The  obstetrician  must  be  notified 
should  bougies  or  bags  be  expelled  or  should  the  membranes 
rupture.  Should  active  labor  develop  vigorously  bougies 
should  be  immediately  removed,  but  the  bag  may  be  left  to 
be  expelled. 

The  Induction  of  Labor  by  Drugs. — Certain  drugs  have 
had  a  more  or  less  deserved  reputation  for  inducing  labor. 
Castor  oil  has  long  enjoyed  this  distinction.  Quinine  has 
proven  reliable  in  some  cases,  'and  worthless  in  others. 
Strychnia  as  a  stimulant  in  weak  patients  will  sometimes  pro- 
duce the  desired  result.  Ergot  has  been  abandoned  because 
it  is  dangerous,  by  all  well-informed  obstetricians. 

Much  has  been  written  concerning  the  specific  action  of 
pituitrin.  This  substance  produces  rapidly  developing  and 
strong  uterine  contractions.  Its  action  is  not  sustained, 
but  is  vigorous  while  it  lasts. 

Unless  dilatation  is  complete,  presentation  and  position 
favorable,  and  the  membranes  ruptured,  with  no  dispropor- 
tion between  mother  and  child,  pituitrin  should  not  be  used. 
With  an  undilated  or  partly  dilated  cervix,  and  without  other 


THE   INDUCTION    OF   LABOR  379 

conditions  favorable  for  spontaneous  delivery,  pituitrin  has 
caused  rupture  of  the  uterus. 

The  Induction  of  Labor  by  Mental  Effect  or  Suggestion.— 
Unquestionably  in  some  patients  labor  can  be  induced  by 
suggestion  only.  The  writer  at  one  time  had  a  patient,  the 
wife  of  a  physician,  who  was  conscious  of  the  fact  that  she 
had  a  contracted  pelvis. 

The  induction  of  labor  was  selected  as  the  mode  of  treat- 
ment, and  accepted  by  husband  and  wife.  At  a  certain  date 
antiseptic  preparations  were  made  for  induced  labor,  and 
during  the  following  night,  without  interference  and  without 
the  action  of  drugs,  labor  developed  and  resulted  spontane- 
ously. 

In  this  case  the  patient  was  fully  aware  of  the  conditions 
present,  the  statement  was  made  positively  to  her  that  labor 
was  coming  on,  and  this  statement  she  believed. 

This  happened  in  three  instances,  and  it  was  never  neces- 
sary in  her  case  to  interfere  or  to  give  drugs,  further  than  an- 
tiseptic preparations  and  the  administration  of  a  simple  lax- 
ative. 

Much  of  the  effect  produced  by  drugs  is  probably  due  to 
mental  suggestion.  In  some  cases  drugs  fail  utterly  to  induce 
uterine  contractions. 

The  most  efficient  and  least  harmful  method  of  inducing 
labor  without  manipulation  consists  in  the  positive  state- 
ment that  labor  will  come  on,  accompanied  by  the  adminis- 
tration of  a  large  dose  of  castor  oil.  If  this  be  followed  by 
a  copious  hot  enema,  or  a  high  colonic  irrigation,  the  desired 
result  will  often  be  produced.  On  the  other  hand,  if  the 
patient  is  very  sensitive  to  suffering,  and  rests  nervously,  and 
is  fearful  of  the  result  of  her  labor,  manipulation  and  the  in- 
troduction of  bougies  and  bags,  may  fail  utterly  to  produce 
normal  uterine  contraction. 

The  Induction  of  Labor  by  Rupture  of  the  Membranes. — 
This  expedient  should  not  be  resorted  to  in  primiparous 
patients  unless  dilatation  is  three-fourths  complete,  and  the 
conditions  all  favorable  for  spontaneous  birth. 

In  multiparous  patients  with  softened  cervix,  with  one- 
half  dilatation,  this  method  is  justifiable.  If  a  moderate 
dose  of  opium  be  given  after  the  rupture  of  the  membranes, 


380  MANUAL   OF    OBSTETRICS 

labor  will  frequently  develop  and  may  terminate  quickly. 
After  the  rupture  of  the  membranes  the  patient  must  wear  a 
sterile  vulvar  dressing  and  must  remain  recumbent. 

Delivery  through  the  Vagina  without  Uterine  Contractions. 
—This  procedure  is  so  dangerous  that  it  is  mentioned  to  be 
condemned.  If  uterine  contractions  cannot  be  induced  the 
patient  should  be  delivered  by  external  means,  the  uterus 
opened  by  incision,  and  immediately  closed  by  suture.  Thus 
the  forcible  dilatation  of  the  cervix  when  the  uterus  does  not 
act,  followed  by  extraction  by  forceps  or  version,  may  be  fol- 
lowed by  severe  shock  and  hemorrhage.  Elective  Cesarean 
section,  on  the  other  hand,  is  accompanied  by  very  little 
shock. 


CESAREAN  SECTION 

This  title  is  used  under  the  belief  that  the  birth  of  Caesar 
was  accomplished  by  abdominal  section.  At  present,  under 
this  general  term,  are  included  several  methods  of  delivery 
by  which  the  child  is  removed  by  incising  the  uterus,  pre- 
ceded by  abdominal  or  vaginal  section. 

At  present  we  distinguish  the  classic  abdominal  Cesarean 
section,  which  is  intraperitoneal ;  extraperitoneal  Cesarean 
section;  delivery  through  a  peritoneal  fistula,  preceded  by 
abdominal  section;  and  vaginal  Cesarean  section. 

THE  CLASSIC  ABDOMINAL  CESAREAN  SECTION 

This  consists  in  opening  the  abdomen,  removing  the 
uterus  from  the  abdominal  cavity,  or  allowing  it  to  remain 
in  the  abdominal  cavity;  opening  the  uterus  by  incision,  ex- 
tracting its  contents,  and  closing  the  uterine  wound  and  the 
peritoneal  and  abdominal  wound.  It  is  obvious  that  in  this 
operation  no  organ  is  removed  and  that  the  patient  is  left 
capable  of  further  procreation. 

Indications. — The  original  indication  for  this  operation 
was  contracted  pelvis  or  such  disproportion  between  mother 
and  child  that  vaginal  delivery  of  a  living  child  was  impossible 
or  delivery  by  embryotomy  highly  dangerous  for  the  mother. 
As  obstetric  surgery  advanced  this  operation  was  used  where 
labor  was  obstructed  by  pelvic  and  abdominal  tumors, 
uterine  or  connected  with  other  organs ;  where  the  fetus  was 
in  an  impossible  presentation  for  spontaneous  birth  and  the 
tetanic  condition  of  the  uterus  threatened  rupture;  where  the 
mother  was  physiologically  unfit  to  develop  the  nervous  and 
muscular  energy  necessary  for  vaginal  birth;  in  placenta 
praevia,  where  so  much  of  the  cervix  is  covered  by  placenta 
that  vaginal  delivery  is  highly  dangerous  for  mother  and 

381 


382  MANUAL    OF   OBSTETRICS 

child;  in  separation  of  the  normally  implanted  placenta,  the 
child  viable  and  in  fair  condition,  with  the  cervix  undilated; 
and  in  eclampsia. 

Elective  Section,  and  Section  during  Labor. — Originally 
Cesarean  section  was  practised,  after  other  methods  of  de- 
livery had  been  unsuccessfully  tried,  as  a  last  resort.  Its 
maternal  and  fetal  mortality  were  inevitably  high.  Later 
it  was,  and  still  is,  used,  after  a  reasonable  test  of  the  natural 
forces  of  labor  has  been  made.  Thus,  where  there  is  not 
great  disproportion  between  mother  and  child,  the  patient 
being  a  vigorous  primipara,  it  may  be  wise  to  make  the  test 
of  labor  to  secure  engagement  and  descent  before  resorting 
to  section. 

Where  a  definite  pathological  condition  is  present  which 
can  be  clearly  distinguished,  and  which  must  make  vaginal 
delivery  dangerous,  the  operation  may  be  a  purely  elective 
one,  at  a  time  chosen  by  the  operator  in  the  best  interests  of 
mother  and  child,  and  without  subjecting  her  to  the  pain  and 
exhaustion  of  labor. 

Methods  of  Performance. — The  classic  abdominal  Cesa- 
rean section  is  done  by  the  majority  of  operators  by  opening 
the  abdomen  and  delivering  the  unopened  uterus  from  the 
abdominal  cavity,  the  intestines  and  other  viscera  being  care- 
fully covered  and  protected  by  large  pads  of  sterile  gauze 
wrung  out  of  hot  salt  solution.  Experience  has  shown  that 
the  amniotic  liquid  ofiten  becomes  infected  after  the  mem- 
branes rupture,  or  from  bacteria  from  the  child's  intestine, 
and  that  the  amniotic  liquid  may  infect  the  peritoneum.  If 
the  uterus  be  removed  from  the  abdominal  cavity,  it  is 
opened  and  the  amniotic  liquid  allowed  to  escape  over  the 
side  of  the  patient,  the  danger  of  contaminating  the  perito- 
neum being  less. 

The  uterus  is  opened  longitudinally  in  the  centre  on  its 
anterior  aspect  through  the  contractile  portion  of  the  womb, 
care  being  taken  to  avoid  the  lower  portion  and  the  lower 
uterine  segment.  The  incision  should  not  be  too  large,  but 
large  enough  to  permit  the  prompt  extraction  of  the  fetus, 
as  the  uterus,  will  contract  during  the  delivery  of  the  child. 
If  the  operator  prefers,  the  incision  can  usually  be  enlarged 
slightly  by  blunt-pointed  scissors,  or  by  the  fingers.  At  the 


THE    CLASSIC   ABDOMINAL    CESAREAN   SECTION 


383 


moment  when  the  uterus  is  opened  some  operators  prefer  to 
have  an  assistant  grasp  the  uterine  arteries  in  the  broad  liga- 
ments, thus  controlling  hemorrhage.  The  uterus  is  turned 
over  one  side  of  the  patient's  body  if  the  membranes  have 
not  ruptured,  so  that  the  amniotic  liquid  may  escape  ex- 
ternally. The  rupture  of  the  membranes  is  followed  by  the 
ii  11  mediate  extraction  of  the  child,  care  being  taken  not  to 
tear  the  uterus.  The  child  is  immediately  handed  to  an 
assistant,  who  clamps  and  cuts  the  umbilical  cord.  The 
placenta  is  then  separated  by  the  gloved  hand  of  the  operator, 


Fig.    139. — Cesarean  section:  the  uterus  eventrated  ready  to  open. 

and  the  membranes  are  carefully  separated  from  the  uterine 
wall.  If  they  are  unduly  adherent  and  tear,  they  may  often 
be  removed  by  grasping  them  with  dry  gauze  or  by  wiping 
the  interior  of  the  uterus  with  dry  gauze.  If  the  membranes 
are  unruptured,  and  the  patient  has  not  been  long  in  labor 
and  is  in  good  condition,  as  little  interference  as  possible 
should  be  practised  in  the  interior  of  the  uterus.  If  the 
patient  has  been  long  in  labor,  with  discolored  membranes  or 
amniotic  liquid,  if  she  has  been  subjected  to  repeated  at- 
tempts at  delivery  and  examination,  and  if  the  uterus  con- 


384 


MANUAL    OF    OBSTETRICS 


tracts  poorly  with  a  tendency  to  hemorrhage,  it  is  well  to 
pour  hot  salt  solution  into  the  uterus  through  this  wound, 
allowing  it  to  escape  through  the  cervix  and  vagina.  The 
uterus  may  then  be  packed  with  10  per  cent,  iodoform  gauze, 
the  end  of  which  is  brought  through  the  cervix  into  the 
vagina. 

The  suture  of  the  uterus  is  the  cardinal  point  in  the  classic 
abdominal  Cesarean  section.  The  uterine  muscle  should 
be  closed  by  interrupted  stitches  of  silk  of  the  best  quality, 
the  stitch  passing  down  to  the  endometrium  and  decidua,  but 


Fig.  140.— Cesarean  section;  delivery  of  the  child. 

not  including  it.  The  stitches  should  not  be  passed  through 
the  peritoneal  covering  of  the  uterus.  The  stitches  should  be 
tied  so  soon  as  they  are  inserted,  when  their  application  im- 
mediately checks  bleeding  and  stimulates  uterine  contrac- 
tion. If  there  are  large  sinuses  in  the  wound  the  stitches 
may  often  be  so  placed  as  to  include  the  sinuses.  These 
stitches  are  carefully  tied  and  cut  short.  The  peritoneal  cov- 
ering of  the  uterus  is  then  closed  by  continuous  stitch  of 
fine  silk  or  catgut,  which  effectually  seals  and  closes  the  womb. 
The  abdomen  is  then  closed  by  bringing  together,  first  the 


THE   CLASSIC   ABDOMINAL   CE8ABBAN    SECTION 


385 


peritoneum  with  fine  silk  or  catgut;  next  the  fascia;  and 
then  the  subcutaneous  tissue  and  the  skin. 

Operators  diff er  in  their  methods  of  closing  the  uterine 
wall  and  the  abdomen,  but  the  essentials  of  uterine  suture  are 
those  described. 

If  gauze  has  been  passed  within  the  uterine  cavity  the 
operation  is  completed  by  sponging  out  the  vagina  with  bi- 
chloride solution,  pulling  down  the  end  of  the  gauze  strip 
until  it  is  satisfactorily  brought  through  the  cervix,  and  ty- 
ing to  it  a  strip  of  bichloride  gauze,  with  which  the  vagina  is 


Fig.  141. — Cesarean  section;  the  uterus  emptied  and  closed  by  suture. 

moderately  tamponed.  This  gauze  is  removed  in  from 
forty-eight  to  sixty  hours.  The  vagina  is  then  sponged  out 
with  antiseptic  solution,  but  no  douches  or  other  interference 
are  practised. 

To  avoid  disturbing  the  abdominal  contents  as  much  as 
possible,  some  prefer  to  incise  the  uterus  in  the  abdomen, 
without  removing  it  from  the  abdominal  cavity.  In  this 
operation  the  abdomen  is  opened  at  and  above  the  umbilicus, 
the  abdominal  wall  separated,  while  the  hands  of  an  assistant 
press  the  abdominal  walls  firmly  against  the  uterus,  and  press 
25 


386 


MANUAL   OF   OBSTETRICS 


the  uterus  upward  into  the  wound.  The  operator  then  in- 
cises the  uterine  wall  and  extracts  the  child.  If  the  cervix 
is  dilated,  some  prefer  to  press  the  placenta  downward,  de- 
livering it  through  the  cervix  into  the  vagina.  Others  re- 
move the  placenta  and  membranes  in  the  usual  manner.  The 
uterus  is  closed  as  described  and  the  abdominal  wall  sutured. 


Fig.  142. — Cesarean  section:  the  abdominal  dressing. 

Those  who  select  this  method  claim  for  it  the  avoidance  of 
shock,  and  ease  and  rapidity  of  operation. 

EXTRAPERITONEAL  SECTION 

This  method  is  based  upon  the  anatomical  fact  that  the 
lower  portion  of  the  abdominal  peritoneum  at  the  pubes  can 
often  be  pushed  upward  from  the  anterior  surface  of  the  ut- 
erus, exposing  the  lower  uterine  segment  without  opening  the 
peritoneal  cavity.  Frank  and  others  have  practised  delivery 
through  the  lower  uterine  segment,  endeavoring  to  avoid 
opening  the  peritoneum. 

Methods  of  Performance. — For  this  operation  some  pre- 
fer to  have  the  urinary  bladder  of  the  patient  completely 


EXTRAPERITONEAL   SECTION  387 

emptied  by  catheter,  while  others  distend  it  partially  with 
boracic  acid  solution,  so  that  it  may  be  the  more  easily  manip- 
ulated. The  incision  is  made  above  the  pubes  and  the  tis- 
sues are  retracted,  the  operator  dissecting  with  the  gloved 
finger  or  with  blunt  scissors,  down  to  the  peritoneum.  This 
is  pushed  upward  as  far  as  possible  and  the  bladder  carried 
to  one  side,  or  if  empty  pushed  downward.  The  lower  uter- 
ine segment,  if  the  patient  is  at  term,  will  then  be  exposed. 
If  she  has  been  for  some  time  in  labor,  and  the  head  has  dis- 
tended the  lower  segment,  it  becomes  more  readily  apparent. 
The  uterus  is  then  opened  longitudinally,  and  an  assistant, 
by  pressing  upon  the  womb,  forces  the  presenting  part  up 
through  the  incision.  Some  operators  prefer  to  immediately 
apply  the  obstetric  forceps,  if  the  head  is  presenting,  and  de- 
liver with  forceps.  It  is  well  to  avoid  version  because  of  the 
danger  of  tearing  the  womb.  After  the  delivery  of  the  child 
the  placenta  is  forced  out  by  Crede's  method  and  is  delivered 
through  the  incision.  If  the  cervix  is  completely  dilated, 
the  operator  may  prefer  to  force  it  downward  through  the 
cervix  and  into  the  vagina  with  the  membranes.  If  there  is 
a  tendency  to  hemorrhage,  or  infection  is  feared,  the  operator 
may  tampon  the  uterus  with  10  per  cent,  iodoform  gauze, 
bringing  the  end  of  the  gauze  through  the  cervix.  The  uter- 
ine wall  is  then  closed  with  several  continuous  catgut  sut- 
ures, in  layers.  A  gauze  cigarette  drain  is  placed  behind  the 
pubes,  and  the  abdominal  wound  is  closed  to  the  drain. 

Delivery  through  Peritoneal  Fistula. — Experience  shows 
that  in  many  cases  of  attempted  extraperitoneal  delivery 
that  the  peritoneum  is  opened,  and  that  it  is  either  repaired 
at  the  close  of  the  operation  or  else  is  stitched  to  the  abdom- 
inal and  uterine  wounds,  and  delivery  is  thus  made  through  a 
peritoneal  fistula. 

By  this  method  it  is  claimed  that  in  cases  where  the  uterus 
is  infected  delivery  may  be  accomplished  with  a  minimum 
danger  of  abdominal  infection  and  peritonitis. 

In  operating  through  a  peritoneal  fistula  the  abdomen 
is  opened  to  the  peritoneum,  and  the  peritoneum  stitched  to 
the  anterior  surface  of  the  uterus  and  to  the  abdominal  wall. 
The  uterus  is  then  opened  through  the  fistula  so  made,  and 
delivery  effected  as  in  extraperitoneal  section.  The  oper- 


388 


MANUAL   OF   OBSTETRICS 


ator,  in  infected  cases,  may  leave  the  peritoneal  fistula  open 
for  complete  drainage,  allowing  it  to  close  by  granulation  as 
the  uterus  undergoes  involution.  In  clean  cases  the  uterine 
muscle  is  closed  and  the  peritoneal  surfaces  above  it  and 
the  abdominal  fascia,  subcutaneous  tissue  and  skin. 

Extraperitoneal  Section  by  Inguinal 
Incision. —  Gailliard  Thomas,  of  New 
York,  and  recently  Doderlein,  of  Mun- 
ich, performed  extraperitoneal  delivery 
by  opening  the  abdomen  above  Poupart's 
ligament  and  parallel  to  it,  carrying  up 
the  lower  portion  of  the  peritoneal  sac 
and  incising  the  uterus  through  the  lower 
segment  and  upper  cervix. 

Thomas  called  this  operation  laparo- 
elytrotomy.  Doderlein  names  it  deliv- 
ery by  inguinal  incision. 

In  the  hands  of  a  skilled  operator  this 
method  can  be  successfully  carried  out. 
Vaginal  Cesarean  Section. — Diihrssen 
and  others  have  accomplished  delivery 
through  the  vagina  in  cases  where  the 
cervix  offers  resistance  by  what  is  termed 
vaginal  Cesarean  section.  This  is  per- 
formed by  drawing  down  the  cervix, 
making  a  transverse  incision  across  the 
anterior  portion  of  the  cervix  at  the 
junction  of  the  vagina,  pushing  up  the 
tissues  which  include  the  peritoneum 
and  the  base  of  the  bladder,  until  the 
lower  segment  is  visible.  The  cervix  is 
then  grasped  by  two  strong  tenaculum 
forceps  and  is  incised  with  blunt-pointed 
scissors  longitudinally,  the  incision  pass- 
ing through  the  lower  segment.  Occa- 
sionally in  cases  where  the  cervix  is  unusually  small  and 
resisting  the  posterior  portion  of  the  cervix  is  also  open. 
If  necessary,  the  membranes  are  ruptured  and  the  child  is 
extracted  by  forceps,  rarely  by  version.  The  placenta,  mem- 
branes and  cord  are  expressed  from  the  uterus.  The  uterus 


Fig.  143.— Extra 
peritoneal  Cesarean 
section  throuh  a  peri- 
toneal fistula.  The 
uterine  peritoneum 
has  been  incised  and 
sutured  to  the  parie- 
tal peritoneum,  thus 
exposing  the  upper 
portion  of  the  cervix 
and  the  lower  uterine 
segment,  which  is  in- 
cised and  through 
which  the  child  is  de- 
livered (after  Liep- 
mann). 


EXTRAPERITONEAL   SECTION 


389 


is  then  packed  with  gauze  and  the  tissues  closed  with  con- 
tinuous buried  catgut  sutures.  The  transverse  incision  is 
brought  together  and  a  small  drain  is  left  at  the  base  of  the 
bladder. 

This  operation  is  obviously  useless  in  contracted  pelvis 
or  where  great  disproportion  exists,  and  is  designed  for  cases 


Fig.  144. — Vaginal  Cesarean  section:  flaps  of  tissue  from  the  an- 
terior vaginal  wall  pushed  back  by  gauze  from  the  cervix.  The  bladder 
pushed  upward  to  avoid  injury. 

where  the  cervix  is  undilated  or  cannot  be  dilated,  where  the 
fetus  is  small  and  where  rapid  delivery  through  the  vagina  is 
indicated. 

Indications  for  the  Classic  Abdominal  Cesarean  Section. — 
This  is  the  most  important  and  widely  used  of  all  forms  of 
delivery  by  incision,  because  it  enables  the  operator  to  deal 
intelligently  with  any  abdominal  complication  and  any  posi- 


390  MANUAL   OF   OBSTETRICS 

tion  and  presentation  of  the  fetus.  It  is  also  applicable  in 
cases  of  septic  infection,  if  followed  by  the  removal  of  the 
body  of  the  uterus. 

In  general,  it  may  be  said  that  abdominal  Cesarean  sec- 
tion is  indicated  in  primiparai  for  considerably  contracted 
pelvis,  great  disproportion,  physiological  incompetence  for 
labor,  diseased  conditions  of  the  uterine  muscle,  or  abnormal 


Fig.  145. — Vaginal  Cesarean  section;  incising  the  anterior  lip  of  the 

cervix. 

conditions  of  the  uterus  caused  by  ventro-suspension  or  mal- 
development;  tumors  of  the  pelvic  or  abdominal  organs  ob- 
structing labor;  abnormal  positions  and  presentations  of 
the  fetus  which  expose  the  mother  to  the  danger  of  uterine 
rupture,  and  the  fetus  to  the  risk  of  its  life;  central  and 
partial  placenta  praevia  and  eclampsis. 
In  multipart,  abdominal  Cesarean  section  is  indicated 


EXTRAPERITONEAL   SECTION  391 

where  in  previous  labors  the  mother  has  lost  a  child  or  chil- 
dren through  birth  pressure  and  difficult  delivery,  where 
pregnancy  is  unduly  prolonged,  and  where  the  indications 
already  mentioned  in  primipane  are  present. 

Abdominal  Cesarean  Section  in  Septic  Cases. — Where 
patients  have  become  infected  through  long  labor  with  un- 
successful attempts  at  delivery  and  repeated  examinations, 


Fig.  146. — Vaginal  Cesarean  section;  the  membranes  protruding  through 
the  incised  cervix. 

delivery  by  abdominal  section  frequently  offers  the  best 
chance  for  the  life  of  the  mother.  It  must  be  followed  by  the 
removal  of  the  body  of  the  uterus  and  the  Fallopian  tubes, 
often  including  the  ovaries.  The  uterine  stump  must  be 
left  outside  the  peritoneal  cavity,  and  this  may  be  accom- 
plished by  using  the  clamp  by  Porro's  original  method,  or 
by  performing  hysterectomy,  and  fastening  the  stump  by 
sutures  to  the  lower  end  of  the  abdominal  incision.  This  ob- 


392  MANUAL    OF   OBSTETRICS 

viously  sterilizes  the  patient  and  raises  the  question,  under 
what  circumstances  should  abdominal  Cesarean  section  be 
followed  by  sterilization? 

Where  the  mother  is  infected,  sterilization  after  section 
is  demanded  in  the  interests  of  her  life.  Where  abdominal 
Cesarean  section  is  elective,  and  if  the  patient  is  in  good 
condition,  sterilization  may  be  performed  when  the  life  and 


Fig.  147. — Vaginal  Cesarean  section:  the  cervix  closed  by  suture. 

health  of  the  mother  are  threatened  by  childbirth;  when 
pathological  conditions  exist  in  the  uterine  muscle;  when 
the  mother  is  insane  or  idiotic,  or  such  a  person  that  the  pro- 
duction of  healthy  children  by  her  is  impossible.  Steriliza- 
tion should  not  be  done  in  persons  mentally  sound  until  it  is 
positively  demonstrated  that  good  and  sufficient  reason  ex- 
ists, and  husband  and  wife  agree  and  request  that  it  be  ac- 
complished. 


EXTRAPERITONEAL   SECTION  393 

In  clean  cases  sterilization  after  section  is  best  effected  by 
performing  hysterectomy,  removing  the  body  of  the  uterus 
and  the  Fallopian  tubes.  If  the  patient  has  not  reached 
the  menopause,  one  or  both  ovaries  may  be  left,  but  if  the 
ovaries  are  cystic,  or  the  patient  is  near  the  menopause,  they 
may  be  removed  with  the  uterus.  In  patients  who  are 
in  good  condition  the  operation  is  often  concluded  by  the  re- 
moval of  the  appendix. 

The  Preparation  for  Cesarean  Section. — Where  ample 
time  is  given  in  elective  cases,  the  patient  should  enter  the 
hospital  one  or  two  days  before  operation,  and  the  abdomen 
should  be  thoroughly  prepared  on  the  day  preceding  delivery. 
Any  reliable  surgical  method  known  to  the  operator  may  be 
selected.  After  preparation  the  abdomen  should  be  covered 
with  sterile  gauze  and  a  bandage.  On  the  morning  of  op- 
eration a  copious  vaginal  douche  of  1  per  cent,  lysol  should  be 
given,  the  bowels  should  be  moved  by  a  cathartic  given 
the  night  previously,  followed  by  a  saline  and  high  saline 
irrigation.  A  vulvar  occlusion  dressing  should  be  worn  after 
preparation. 

When  the  patient  is  anesthetized  she  should  be  catheter- 
ized,  the  abdominal  dressing  removed,  and  tincture  of  iodine 
applied  over  the  abdominal  surface. 

Sleep  should  be  secured  on  the  night  preceding  operation 
by  veronal  given  with  broth,  or  soup,  or  with  whiskey  and 
water. 

One  arm  of  the  patient  should  be  prepared  for  intravenous 
saline  transfusion,  and  appliances  should  be  at  hand  for  irri- 
gating the  stomach  at  the  conclusion  of  the  operation. 
While  in  emergencies  it  is  possible  to  perform  Cesarean  sec- 
tion in  private  houses,  these  operations  should  be  done,  as  a 
rule,  in  hospital. 

In  the  interests  of  the  child,  a  basket  suitably  prepared 
and  warmed  with  hot  bottles  should  be  in  readiness,  also  ap- 
pliances for  resuscitation. 

Anesthesia  and  Assistants. — For  Cesarean  section  an 
experienced  obstetric  anesthetizer  is  necessary.  Owing  to 
the  size  of  the  abdominal  tumor  the  patient  often  breathes 
with  difficulty  during  the  first  stage  of  the  operation.  So  soon 
as  the  uterus  is  emptied  a  considerable  change  occurs  in  res- 


394  MANUAL   OF   OBSTETRICS 

piration  and  blood  pressure.  While  anesthesia  should  be 
complete  it  should  not  be  so  heavily  pushed  that  the  patient 
is  deeply  narcotized  when  the  child  is  delivered.  Deep  nar- 
cosis may  prevent  the  prompt  contraction  of  the  uterus  and 
may  unfavorably  affect  the  child.  Ether  is  the  anesthetic 
of  choice,  and  oxygen  should  be  used  freely  with  it.  The 
vital  condition  of  the  patient  should  receive  attention  from 
the  anesthetizer  and  if  the  uterus  is  to  be  retained,  a  hypo- 
dermatic syringeful  of  ergot  should  be  injected  into  the  thigh 
or  arm  so  soon  as  the  child  is  delivered.  Strychnia  and 
atropin  given  hypodermatically  are  also  useful. 

In  Cesarean  section  the  chief  assistant  controls  hemorrhage 
by  pressure  in  the  manner  desired  by  the  operator,  and 
guards  against  the  infection  of  the  peritoneal  cavity  by  am- 
niotic  liquid,  and  by  surrounding  the  uterus  with  gauze  pads 
wrung  out  of  hot  sterile  salt  solution,  stimulates  it  to  con- 
traction. The  assistant  who  receives  the  child  should  have 
ready  appliances  for  clamping,  tying  and  cutting  the  cord  and 
for  resuscitating  the  child,  if  necessary. 

Many  children  born  by  elective  Cesarean  section  do  not 
breathe  freely,  nor  cry  for  a  few  moments,  because  of  the 
suddenness  of  birth  and  the  absence  of  birth  pressure  which 
accompanies  spontaneous  delivery. 

If  the  patient  is  toxemic  or  exhausted  or  anemic,  it  is  well 
to  inject  into  a  vein  of  the  arm  from  16  to  24  ounces  of  sterile 
salt  solution.  This  should  be  done  as  the  operation  is  near- 
ing  its  end.  If  she  has  suffered  from  nausea  during  her 
pregnancy  and  is  toxemic,  before  leaving  the  operating  table 
the  stomach  should  be  gently  but  thoroughly  irrigated  with 
hot  sterile  salt  solution.  In  performing  Cesarean  section  it 
is  essential,  if  possible,  that  the  operator  should  have  the 
advantage  of  trained  assistants  who  are  accustomed  to  work 
with  him.  Much  valuable  time  is  saved,  and  operations  are 
done  much  more  safely  and  successfully. 

Dressings. — After  abdominal  Cesarean  section,  where 
the  uterus  is  left  and  closed,  a  firm  pad  of  sterile  gauze  should 
be  placed  upon  the  fundus,  and  the  abdominal  incision  cov- 
ered by  a  copious  gauze  dressing.  The  dressing  should  be 
completely  covered  by  broad  strips  of  adhesive  plaster  ap- 
plied from  above  downward  and  extending  two-thirds  of  the 


EXTRAPERITONEAL   SECTION  395 

way  around  the  patient's  body.  These  should  overlap  so 
that  the  dressing  is  completely  enclosed,  and  firm  uniform 
pressure  made.  Over  this  may  be  placed  the  ordinary  many- 
tailed  surgical  binder.  A  firm  abdominal  dressing  is  most 
important  after  Cesarean  section,  as  the  incision  is  often  a 
long  one;  the  abdominal  walls  are  relaxed,  and  unless  firm 
and  lasting  support  be  given,  in  vomiting  the  patient  might 
burst  the  abdominal  incision  and  cause  a  knuckle  of  intestine 
to  protrude.  The  usual  sterile  vulvar  dressings  should  also 
be  employed. 

After-treatment. — After  Cesarean  section  the  treatment 
usually  given  to  surgical  patients  is  indicated.  Ergot  should 
not  be  given,  but  tonic  doses  of  strychnia  with  or  without 
digitalin,  given  hypodermatically  until  the  patient  is  retain- 
ing by  the  stomach,  are  indicated.  Morphia  may  be  used 
once  or  twice  if  necessary,  and  codein  afterward  hypoder- 
matically. For  gas,  enemas  of  assafetida,  and  for  distention, 
high  purgative  enemas,  are  useful.  If  vomiting  is  severe  the 
stomach  should  again  be  irrigated.  As  pregnant  patients  are 
usually  constipated,  it  is  well  to  move  the  bowels  on  the  sec- 
ond or  third  day  by  small  doses  of  calomel  and  soda,  followed 
by  a  saline  and  by  an  intestinal  irrigation  or  high  enemas. 

Albumen  water  should  be  the  first  nourishment  allowed, 
and  other  liquids  may  be  given  as  the  patient  can  take  them. 

When  the  patient  has  recovered  from  the  anesthesia  she 
may  nurse  the  child,  and  by  the  second  or  third  day  should 
nurse  the  child  every  four  or  three  hours  during  the  day,  and 
once  at  night.  When  her  digestion  is  established  she  should 
have  milk  and  milk  foods  in  abundance,  cereals,  cooked 
fruit,  and  vegetables  in  season. 

On  the  average,  the  stitches  may  be  removed  from  the 
tenth  to  the  fourteenth  day,  and  the  patient  allowed  to  be  out 
of  bed  at  the  end  of  the  second  week,  and  if  she  has  good  care 
at  home  may  leave  the  hospital  at  the  end  of  the  third  or 
fourth  week. 

The  Care  of  the  Child. — At  birth,  attention  must  be  given 
to  secure  the  establishment  of  respiration,  and  when  this 
is  accomplished  the  Cesarean  child  needs  none  but  the  usual 
care.  Until  it  obtains  nourishment  from  the  mother  it  may 
be  given  albumin  water  or  a  diluted  formula  of  modified 


396  MANUAL   OF   OBSTETRICS 

milk.  As  it  may  lack  the  mother's  colostrum,  the  intestine 
should  be  irrigated  with  equal  parts  of  boiled  water  and  salt 
solution,  and  meconium  brought  away  as  soon  as  possible. 

If  the  child  has  been  subjected  to  birth  pressure  through 
long  labor  or  is  exhausted  through  maternal  hemorrhage,  it 
may  require  stimulus  and  artificial  feeding. 

Complications. — Where  pathological  conditions  of  the 
uterus  or  pelvic  and  abdominal  tissues  exist,  abdominal  Ce- 
sarean  section  may  be  complicated  by  unusual  hemorrhage 
at  the  time  of  delivery.  In  165  operations  the  writer  has 
seen  this  happen  three  times,  once  because  the  intestine  had 
become  adherent  to  the  broad  ligament  where  the  veins  were 
greatly  enlarged,  and  as  the  uterus  lessened  in  size  after  de- 
livery the  broad  ligament  was  torn  and  hemorrhage  ensued. 
It  was  promptly  controlled  by  suture. 

In  another  case,  where  the  uterus  contained  fibroid  tu- 
mors there  was  unusual  hemorrhage  when  the  uterus  was 
incised,  which  was  controlled  by  hysterectomy,  which  had 
been  selected  as  the  method  of  operation  before  the  abdomen 
was  opened. 

In  a  third  case,  in  terminating  abdominal  Cesarean  sec- 
tion by  hysterectomy,  a  clamp  burst  an  enlarged  vein  in  the 
broad  ligament,  and  during  convalescence  a  hematoma  formed 
which  was  subsequently  evacuated  by  vaginal  incision. 

In  none  of  these  cases  did  the  complications  seriously  jeop- 
ardize the  patient's  recovery. 

The  veins  of  the  broad  ligaments  are  enormously  dis- 
tended at  full  term,  and  care  must  be  taken  in  operating  not 
to  wound  them  or  bruise  them. 

The  placenta  is  frequently  under  the  incision  through  the 
uterine  wall.  At  first  sight,  this  causes  considerable  bleeding, 
but  if  the  operator  disregards  the  first  flow  it  is  questionable 
whether  any  essential  increase  in  blood  loss  actually  occurs. 
Possibly  the  danger  of  infection  is  greater  because  the  large 
uterine  sinuses  are  closed  by  the  uterine  sutures,  and  should 
one  of  these  sutures  be  infected  the  danger  to  the  patient 
would  be  greater. 

So  far,  in  the  writer's  experience,  he  has  been  able  to  cause 
the  uterus  to  contract  efficiently,  and  has  not  seen  post- 
partum  bleeding  after  Cesarean  section. 


EXTRAPERITONEAL   SECTION  397 

In  cases  where  the  child  is  unusually  large,  the  uterine 
incision  may  bo  torn  during  delivery,  and  very  rarely  it  is 
necessary  to  perform  hysterectomy.  Death  has  followed 
delivery  by  Cesarean  section,  because  catgut  stitches  buried 
in  the  uterine  muscle  became  loosened  and  fatal  hemorrhage 
followed.  Neither  of  these  complications  has  come  under 
the  observation  of  the  writer. 

The  complication  most  to  be  feared  is  septic  infection. 
This  kept  the  mortality  of  delivery  by  abdominal  Cesarean 
section  so  high  that  for  many  years  the  operation  was  in  dis- 
credit. At  present  we  know  that  every  vaginal  examination 
and  every  attempt  to  deliver  during  labor  causes  infection  in 
some  degree  in  a  parturient  patient.  It  is  practically  im- 
possible to  manipulate  the  cervix  without  carrying  bacteria 
from  the  vagina  into  the  cervix.  Operators  then  fear  es- 
pecially those  cases  brought  to  them  from  the  practice  of 
others,  where  repeated  examinations  have  been  made  and 
attempts  at  delivery  carried  out  under  unfavorable  surround- 
ings and  with  very  indifferent  antiseptic  technic.  All  such 
patients  must  be  considered  as  infected,  or  at  least  as  sus- 
pected cases.  Where  the  operator  finds  the  membranes  dis- 
colored and  the  amniotic  liquid  offensive  at  operation,  he 
recognizes  intra-amnial  infection  as  present.  In  both  these 
classes  of  cases  it  is  sometimes  difficult  to  decide  what  is 
best  in  the  interests  of  the  mother.  Unquestionably  in  sus- 
pected and  infected  cases,  the  mother  is  safest  if  the  body 
of  the  uterus  and  Fallopian  tubes  are  removed  after  delivery; 
but  in  young  women  this  seems  an  excessive  procedure,  and 
the  writer  has  had  good  results  by  irrigating  the  uterus  thor- 
oughly with  hot  salt  solution  and  packing  and  draining  it  with 
10  per  cent,  iodoform  gauze.  These  patients  have  a  moder- 
ate rise  of  temperature  for  several  days  after  the  operation, 
but  have  recovered,  retaining  the  uterus  in  sound  condition. 

Where  cases  are  brought  to  operators  where  one  or  more 
unsuccessful  attempts  have  been  made  with  forceps,  the  pa- 
tient having  been  long  in  labor  and  the  child  subjected  to 
birth  pressure  and  forceps  pressure,  it  may  be  wise  to  decline 
abdominal  Cesarean  section  of  any  variety  and  to  terminate 
labor  by  craniotomy  or  some  other  form  of  embryotomy. 
Delivery  through  a  peritoneal  fistula  following  labor,  leaves 


398  MANUAL   OF   OBSTETRICS 

the  mother  with  a  tedious  convalescence  and  with  the  uterus 
adherent  to  the  abdominal  wall. 

Results  of  Abdominal  Cesarean  Section. — At  present,  in 
the  hands  of  experienced  operators,  clean  cases  subjected  to 
abdominal  Cesarean  section  should  not  have  a  maternal  mor- 
tality exceeding  2  per  cent.,  and  a  fetal  mortality  of  prac- 
tically nil.  From  this  standard  the  mortality  rises  steadily 
in  proportion  with  the  number  of  examinations  and  attempts 
at  delivery  made  before  the  operation,  the  length  of  time  oc- 
cupied in  operation,  the  amount  of  previous  hemorrhage, 
the  method  of  operation  selected,  and  the  presence  or  ab- 
sence of  infection. 

The  classic  abdominal  section  can  be  done  from  the  in- 
cision through  the  skin  to  the  completion  of  the  dressing  in  a 
considerable  series  of  cases  in  thirty-five  minutes.  Hys- 
terectomy by  the  Porro  method  is  not  longer,  and  often 
slightly  shorter.  Elective  hysterectomy,  removing  the  tubes, 
is  somewhat  longer. 

No  greater  mistake  can  be  made  than  to  deliver  a  septic 
patient  by  abdominal  Cesarean  section,  performing  hys- 
terectomy, and  then  dropping  the  stump.  Such  patients  in 
a  large  proportion  die  from  sepsis.  The  complete  removal  of 
the  septic  uterus  was  ideally  the  operation  of  choice,  but 
practically  extirpation  of  the  uterus  at  full  term  is  not  easy 
and  is  often  accompanied  by  considerable  hemorrhage,  and 
the  results  are  not  so  good  as  those  obtained  by  hysterectomy 
with  the  stump  outside  the  peritoneal  cavity.  A  fatal  mis- 
take would  be  made  by  an  operator  who  performed  abdominal 
Cesarean  section  upon  a  septic  case  where  sepsis  was  un- 
questionably present,  and  sutured  and  left  the  uterus.  So, 
in  dealing  with  the  fibroid  uterus,  if  the  incision  cannot  be 
made  through  sound  tissue  the  body  of  the  womb  must  be 
removed.  If  there  is  ample  space  for  incision  through  sound 
tissue,  and  the  fibroids  are  small,  the  uterus  may  often  be 
left  and  the  fibroids  may  undergo  involution. 

In  general,  it  may  be  said  that  two-thirds  of  septic  cases, 
where  abdominal  Cesarean  section  is  indicated,  can  be  saved 
by  hysterectomy  with  the  stump  outside  the  peritoneal  cav- 
ity. In  placenta  prsevia,  where  the  whole  or  the  greater 
part  of  the  cervix  is  covered  by  placental  tissue,  and  the 


EXTRAPERITONEAL   SECTION  399 

patient  is  uninfected,  having  had  no  vaginal  manipulation  nor 
packing,  abdomina]  Cesarean  section  gives  good  results  and 
instantly  stops  the  hemorrhage.  Up  to  the  present  time,  the 
writer  has  performed  abdominal  Cesarean  section  on  18  cases 
of  placenta  praevia  with  the  recovery  of  all  the  mothers.  To 
be  successful  in  placenta  prsevia  and  separation  of  the  pla- 
centa, abdominal  Cesarean  section  must  be  done  promptly 
and  before  repeated  examinations  and  manipulations  have 
been  practised.  To  obtain  this  result  such  cases  must  be 
sent  to  hospital  on  the  appearance  of  the  first  considerable 
hemorrhage.  Vaginal  Cesarean  section  is  contraindicated 
in  placenta  pravia  because  the  incisions  are  made  through 
the  site  of  the  placenta,  which  is  unusually  vascular,  and  the 
condition  of  which  invites  infection. 

In  eclampsia  methods  to  secure  elimination,  by  bleeding 
and  transfusion,  gastric  lavage  and  calomel,  and  intestinal 
irrigation,  are  first  indicated.  With  an  undilated  or  undilata- 
ble  cervix  abdominal  Cesarean  section  offers  a  fair  prospect 
of  success. 

The  success  of  abdominal  Cesarean  section  lies  in  its 
prompt  employment  in  properly  selected  cases.  To  obtain 
this  the  complications  of  labor  must  be  considered  as  seri- 
ously as  appendicitis  or  ruptured  ectopic  gestation,  and  cases 
of  complicated  labor  must  be  sent  promptly  to  hospital. 

The  field  of  vaginal  Cesarean  section  lies  in  the  earlier 
months  of  pregnancy  before  viability,  and  in  cases  where 
prompt  delivery  is  required  and  where  the  cervix  is  undilated. 


CHAPTER  XXV 
ENLARGEMENT  OF  THE  PELVIS 

Symphysiotomy;  Pubiotomy;  Lessening  the  Size  of  the 
Sacral  Promontory 

Where  moderate  disproportion  exists  between  mother  and 
child,  it  is  possible  by  severing  the  pelvic  girdle,  or  by  less- 
ening the  size  of  the  sacral  promontory,  to  gain  sufficient 
space  to  permit  delivery. 

SYMPHYSIOTOMY 

If  the  tissue  between  the  two  halves  of  the  pubic  joint  be 
cut,  and  the  ligamentum  arcuatum  or  subpubic  ligament 
be  severed,  the  two  halves  of  the  pelvis  separate,  rotating 
at  the  sacro-iliac  joints.  From  ^  to  1^  cm.  is  gained  in  the 
oblique  diameters  of  the  pelvic  brim,  and  from  ^  to  1  cm. 
in  the  antero-posterior  diameter.  This  operation  is  known 
as  symphysiotomy. 

Indications. — The  object  of  symphysiotomy  is  to  save  the 
life  of  the  child  without  damaging  the  mother.  If  the  pubes 
be  severed  in  a  primipara  hi  whom  the  birth  canal  is  not 
dilated  and  is  not  readily  dilatable,  the  bringing  of  the  child's 
head  through  the  undilated  vagina  may  result  hi  serious 
laceration.  The  tissues  about  the  cervix  and  upper  portion 
of  the  vagina  may  be  brought  forcibly  against  the  cut  ends 
of  the  pubes,  and  extensive  laceration  sometimes  extending 
into  the  pelvic  cavity  and  accompanied  by  severe  or  fatal 
hemorrhage  may  result. 

Hence  symphysiotomy  is  not  indicated  in  primiparse  or  in 
patients  where  the  birth  canal  is  undilated  or  undilatable. 
It  finds  its  best  success  in  multipart  where  disproportion 
between  mother  and  child  is  not  great;  where  mother  and 
child  are  in  good  condition;  and  where  the  head  of  the  child 
is  presenting  in  a  favorable  position. 

400 


SYMPHYSIOTOMY  401 

An  example  of  a  case  appropriate  for  symphysiotomy 
would  be  a  multipara,  who  in  her  third  or  fourth  pregnancy 
was  found  to  have  a  child  so  large  that  it  could  not  be  born 
without  great  difficulty  through  the  pelvis.  The  enlarge- 
ment obtained  by  symphysiotomy  might  permit  the  birth 
of  such  a  child. 


Fig.  148. — Symphysiotomy:  the  symphysis  laid  open,  showing  the 
bladder  and  the  veins  which  may  be  wounded  in  forcible  delivery  after 
the  operation. 

The  Method  of  Performing  the  Operation. — The  method 
usually  employed  is  that  known  as  the  subcutaneous.  It 
consists  in  making  an  incision  just  above  the  pubes  from  one 
to  two  inches  in  length  longitudinally.  The  bladder  should 
previously  have  been  emptied  by  catheter,  and  a  catheter 

or  sound  placed  in  the  urethra,  and  the  urethra  carried  out 
26 


402  MANUAL   OF   OBSTETRICS 

of  the  median  line  to  one  side.  With  the  fingers  of  the  gloved 
hand  the  loose  connective  tissue  between  the  pubes  and  the 
peritoneal  sac  is  invaded,  the  peritoneum  pushed  upward, 
and  the  urethra  and  bladder  to  one  side  and  the  fingers  are 
passed  beneath  the  pubic  joint.  Guided  by  them,  a  blunt- 
pointed  bistoury,  or  a  strong  sickle-shaped,  blunt-pointed 
knife,  is  passed  beneath  the  joint,  and  the  cartilage  is  severed 
from  behind  forward,  and  from  above  slightly  downward. 
When  this  is  done,  the  ends  of  the  pubes  separate  somewhat, 
but  this  is  not  complete  until  the  subpubic  ligament  is  sev- 
ered. To  accomplish  this  the  same  knife  may  be  employed, 
or  a  bistoury  or  scalpel  guided  by  the  fingers.  When  the 
joint  is  completely  cut  through,  the  two  halves  of  the  pubes 
at  once  separate,  so  that  from  two  to  three  fingers  can  be 
placed  between  them. 

Some  prefer  to  sever  the  symphysis  after  making  the  in- 
cision through  the  skin  above  the  joint,  by  a  chain  saw  passed 
about  the  pubes,  or  by  a  strong  scalpel  guided  by  vision,  to 
the  fingers  behind  the  joint. 

Others  have  preferred  to  cut  down  upon  the  joint  from  in 
front,  and  passing  the  finger  from  below  upward  behind  the 
joint,  to  guard  the  tissues  while  the  joint  is  opened.  This 
by  some  has  been  called  the  open  method. 

Various  instruments  have  been  used  in  symphysiotomy, 
a  fine  wire  saw  and  the  metacarpal  saw  being  the  least  often 
used. 

Delivery  after  Symphysiotomy. — As  the  operation  is  not 
performed  until  the  cervix  is  dilated,  the  operator  may  pro- 
ceed at  once  to  complete  delivery.  The  head  is  usually 
found  in  the  pelvic  cavity  or  on  the  pelvic  floor,  and  in  many 
cases  the  occiput  is  posterior.  For  delivery,  the  patient  is 
placed  upon  her  back  at  the  edge  of  a  table,  with  the  limbs 
flexed,  and  the  two  halves  of  the  pelvis  are  steadied  and  sup- 
ported by  assistants.  Delivery  is  effected  by  forceps,  and 
care  must  be  taken  not  to  make  traction  upward,  to  avoid 
wounding  the  tissues  against  the  cut  edges  of  the  pubes. 
After  the  delivery  of  the  child,  the  placenta,  membranes  and 
cord  are  expressed  and  the  uterus  packed  with  iodoform 
gauze.  Especial  care  must  be  taken  to  inspect  the  cervix 
and  the  tissues  about  the  cervix,  and  lacerations  should  be 


PUBIOTOMY  403 

immediately  closed  with  chromicized  catgut.  The  region 
about  the  urethra  and  the  clitoris  should  be  examined  care- 
fully, for  lacerations  sometimes  occur  in  these  tissues  which 
may  cause  annoying  or  even  dangerous  hemorrhage.  A  small 
gauze  drain  is  placed  in  the  symphysiotomy  wound  and  the 
balance  of  the  wound  closed  by  sutures,  the  pelvis  is  im- 
mobilized by  a  broad  strip  of  adhesive  plaster  passed  over  the 
trochanters  and  over  the  pubes  and  sacrum.  If  the  urethra 
has  been  bruised  during  delivery,  or  if  there  is  reason  to  fear 
that  the  base  of  the  bladder  has  been  injured,  a  permanent 
soft  catheter  should  be  left  in  the  bladder. 

The  Results  of  Symphysiotomy. — In  favorable  cases  con- 
nective tissue  forms  between  the  halves  of  the  pubes  suffi- 
ciently firm  to  keep  the  pubes  in  comparatively  good  appo- 
sition. Bony  tissue  rarely  develops,  nor  does  the  joint 
assume  its  former  characteristics.  Some  motion  may  be 
present  between  the  halves  of  the  pubic  bone  for  some  time 
after  the  operation. 

If  the  delivery  has  been  difficult,  one  or  both  sacro-iliac 
joints  may  be  strained  during  delivery,  and  the  patient  may 
have  pain  and  disability  in  that  region.  The  pelvis  after 
symphysiotomy  remains  permanently  enlarged,  but  hi  a 
small  degree  only. 

Some  patients'  convalescence  is  retarded  by  inability  to 
walk,  for  which  no  anatomical  cause  can  be  found.  Patients 
are  kept  in  bed  from  two  to  three  weeks,  and  when  they  be- 
gin to  walk,  wear  for  a  short  time  a  strong  canvas  belt. 

PUBIOTOMY 

The  pelvic  girdle  may  be  opened  by  severing  the  pubic 
bone  through  the  ramus  of  the  pubes  and  not  at  the  joint. 

Indications  for  Pubiotomy. — The  same  indications  which 
pertain  in  symphysiotomy  are  applicable  for  pubiotomy. 
The  operation  has  the  same  indications  and  the  same 
dangers  which  symphysiotomy  has  demonstrated. 

Methods  of  Performance. — Pubiotomy  is  most  often  done 
by  passing  a  needle  upon  a  handle  behind  the  pubic  bone  and 
causing  it  to  emerge  at  the  edge  of  the  ramus  of  the  pubes. 
A  silk  ligature  may  be  used  from  the  needle  to  draw  a  fine 
wire  saw  through  the  opening  thus  made.  The  pubic  bone 


404 


MANUAL   OF   OBSTETRICS 


Fig.   149. — Pubiotomy.     Introducing   the  curved  needle  beneath  the 
ramus  of  the  left  pubes  (Liepmann). 


Fig.  150. — Pubiotomy.     The  fine  saw  is  drawn  through  with  which 
the  pubic  bone  is  severed  (Liepmann). 


MERCURIO's    AND    WALCHER'.S    POSITION  405 

is  severed  by  the  saw,  and  the  saw  withdrawn.  The  small 
openings  are  closed  by  a  single  stitch  or  by  collodion. 

Some  have  preferred  the  open  method,  cutting  down  upon 
the  bone,  and  passing  the  saw  with  the  aid  of  vision  and  touch. 
The  left  half  of  the  pubes  is  usually  selected  for  section,  as 
the  presenting  part  was  originally  directed  toward  this  point. 
The  pelvis  separates  after  pubiotomy,  as  it  does  after  sym- 
physiotomy,  and  delivery  is  effected  in  the  same  manner. 
The  pelvis  is  immobilized,  and  the  patient  usually  kept  in  bed 
from  ten  days  to  two  weeks.  In  favorable  cases  sufficient 
union  results  to  enable  her  to  resume  her  usual  mode  of  life 
in  three  or  four  weeks. 

Pubiotomy  as  a  Prophylactic  Measure. — In  cases  where 
moderate  disproportion  is  present,  but  the  operator  believes 
that  the  head  can  be  brought  through  the  pelvis  with  but 
slight  enlargement  of  the  pelvic  brim,  the  fine  wire  saw  may 
be  applied  to  the  pubic  bone  before  traction  is  made  by  the 
forceps.  A  tentative  traction  by  forceps  is  then  cautiously 
carried  out,  and  if  the  head  does  not  descend  readily  the 
pubic  bone  is  severed. 

In  selected  cases  the  results  of  symphysiotomy  and  pubi- 
otomy are  good  for  mother  and  child.  These  operations 
have  but  a  narrow  field,  as  the  conditions  necessary  for  their 
successful  performance  are  not  often  encountered.  They 
are  incompetent  to  deal  with  the  more  important  complica- 
tions of  parturition,  and  both  operations  are  less  practised 
now  than  formerly.  For  the  child,  both  are  life-saving  oper- 
ations, and  unless  an  error  has  been  made  in  estimating  the 
comparative  size  of  the  fetus  and  the  pelvis,  these  operations 
should  give  good  results. 

ENLARGEMENT   OF  THE  PELVIS  BY  LESSENING  THE  SIZE 
OF  THE  PROMONTORY  OF  THE  SACRUM 

To  increase  the  anterior-posterior  diameter  of  the  pelvic 
brim  a  portion  of  the  promontory  of  the  sacrum  has  been 
removed  by  operation.  A  considerable  gain  in  this  diameter 
results.  The  operation  is  too  recent  at  present  to  give  a  defi- 
nite idea  of  its  value. 

Mercurio's  and  Walcher's  Position. — It  is  possible  to  en- 
large somewhat  the  capacity  of  the  pelvic  brim  by  placing 


406 


MANUAL    OF   OBSTETRICS 


the  patient  in  Mercurio's  or  Walcher's  position.  This  con- 
sists in  placing  the  patient  upon  her  back  at  the  edge  of  a 
high  padded  table,  so  that  the  trunk  of  her  body  rests  upon 
the  posterior  surface  of  the  sacrum.  The  table  should  be  so 
high  that  when  the  patient's  lower  extremities  are  allowed 


Fig.  151. — Delivery  of  patient  in  Walcher's  position  with  axis-traction 

forceps. 

to  hang  freely,  the  feet  do  not  touch  the  floor.  The  patient 
is  kept  in  this  position  by  two  assistants,  who  grasp  the  sides 
of  the  pelvis.  The  weight  of  the  thighs,  if  the  lower  ex- 
tremities are  rotated  outward,  is  sufficient  to  cause  the  two 
halves  of  the  pelvis  to  rotate  at  the  sacro-iliac  joints,  thus  en- 


MERCURIO'S    AND    WALCHER's    POSITION  407 

larging  the  oblique  diameters  of  the  pelvic  brim.  If  the 
forceps  be  applied  with  the  patient  in  this  position  it  is  pos- 
sible to  make  traction  downward  and  backward  at  the  pelvic 
brim  to  advantage,  and  thus  to  deliver  some  cases  where 
otherwise  craniotomy  would  be  necessary.  As  the  head  of 
the  child  comes  upon  the  pelvic  floor  the  thighs  should  be 
flexed  and  drawn  upward  upon  the  patient's  abdomen.  This 
will  relax  the  tissues  at  the  outlet  of  the  pelvis  and  tend  to 
prevent  serious  laceration. 

Mercurio's  position  is  most  successful  in  young  patients 
in  whom  the  pelvic  joints  are  mobile  and  in  whom  the  tissues 
are  elastic.  It  requires  two  strong  assistants  to  hold  the 
patient  upon  the  table,  as  she  must  be  placed  so  far  over  the 
edge  that  if  care  were  not  taken  she  would  be  pulled  off  from 
the  table  by  the  weight  of  the  thighs. 


CHAPTER  XXVI 
RUPTURE  OF  THE  UTERUS 

This  serious  and  often  fatal  accident  may  occur  during 
spontaneous  labor,  in  the  early  months  of  gestation,  or  during 
the  performance  of  some  method  of  operative  delivery. 

Etiology. — The  uterus  ruptures  because  its  muscle  is  dis- 
eased or  over-distended,  or  through  violence  applied  in  un- 
skilful efforts  to  effect  delivery. 

Signs  and  Symptoms  of  Uterine  Rupture.— In  the  early 
months  of  pregnancy,  where  no  interference  has  been  prac- 
tised, rupture  of  the  uterus  may  not  be  immediately  dis- 
covered. The  escape  of  the  uterine  contents  into  the  pelvic 
and  peritoneal  cavities  will  be  followed  by  signs  and  symp- 
toms of  infection. 

An  accurate  diagnosis  can  rarely  be  made  in  these  cases 
unless  operation  is  performed,  the  abdomen  opened,  and  the 
uterus  directly  inspected. 

When  the  uterus  ruptures  during  labor  the  symptoms  are 
characteristic  and  significant.  The  patient  experiences  sud- 
den sharp  pain  in  the  abdomen  followed  by  shock.  The 
characteristic  contractions  of  the  uterus  in  labor  at  once 
cease.  The  patient's  pulse  becomes  rapid  and  weak,  and 
unless  prompt  measures  are  taken,  signs  of  infection  soon 
develope. 

Where  the  patient  is  under  anesthesia,  and  vaginal  delivery 
is  accomplished,  rupture  of  the  uterus  may  not  be  known  until 
the  operator  introduces  his  hand  to  remove  the  placenta, 
when  the  hand  may  pass  through  the  uterine  wall  at  the 
point  of  laceration,  or  when  the  intestine  may  be  found  pro- 
lapsed through  the  tear  into  the  uterine  cavity. 

Signs  of  Threatened  Uterine  Rupture. — In  cases  where 
spontaneous  parturition  is  impossible,  as  in  shoulder  presen- 
tation, brow  presentation,  abnormally  large  child  and  mod- 

408 


RUPTURE  OF  THE  UTERUS 


409 


erately  contracted  pelvis,  the  lower  segment  becomes  enor- 
mously stretched  by  the  contraction  and  retraction  of  the 
upper  segment.  The  lower  edge  of  the  upper  segment  can 
be  felt  as  a  distinct  ridge,  which  slowly  proceeds  upward  in 
the  abdomen  of  the  patient  as  the  distention  of  the  lower  seg- 
ment increases. 


Fig.  152. — Rupture  of  the  uterus  by  the  left  blade  of  the  forceps 

(Liepmann). 

This  ridge  is  often  called  Bandl's  ring,  from  the  name  of 
the  author  who  first  drew  attention  to  it. 

The  condition  of  the  uterine  muscle  during  prolonged 
labor  is  often  a  valuable  indication  of  threatened  rupture. 
In  normal  labor  the  uterus  contracts  and  relaxes,  but  when 
the  uterus  becomes  over-distended  it  passes  oftentimes  into  a 
tetanic  condition,  in  which  the  uterus  feels  firm  and  resisting 


410  MANUAL   OF   OBSTETRICS 

upon  palpation,  is  painful  on  pressure,  and  prevents  effectu- 
ally the  recognition  of  the  position  and  presentation  and  heart 
sounds  of  the  fetus.  This  condition  of  uterine  tetanus  points 
to  the  distended  state  of  the  lower  segment,  and  is  a  valu- 
able indication  of  threatened  rupture. 

The  Results  of  Uterine  Rupture. — In  shoulder  presenta- 
tion, transverse  position,  the  uterus  usually  tears  obliquely 
or  transversely  across  the  anterior  surface.  In  other  ab- 
normal positions  and  presentations  the  direction  of  the  tear 
varies  in  accordance  with  the  circumstances  present.  Oc- 
casionally the  uterus  tears  longitudinally. 

Rupture  of  the  uterine  wall  is  followed  by  the  escape  of 
some  of  the  uterine  contents  into  the  pelvic  or  abdominal 
cavity.  Where  the  rupture  is  slight  in  extent  and  not  com- 
plete, a  loop  of  cord  may  escape  or  one  of  the  fetal  limbs. 
Where  the  rupture  is  transverse  or  oblique,  and  extensive, 
the  entire  uterine  contents  may  be  found  in  the  pelvis  and 
abdomen.  In  other  cases  only  the  greater  portion  of  the 
body  of  the  child  may  escape.  The  result  of  the  escape  of 
the  uterine  contents  into  the  pelvic  or  abdominal  cavities 
is  infection.  Hemorrhage  varies  in  accordance  with  the  ex- 
tent, direction,  and  location  of  the  injury.  It  is  often  severe 
enough  to  greatly  prostrate  the  patient,  and  to  assist  in  the 
development  of  infection.  Death  must  inevitably  follow 
uterine  rupture,  if  extensive,  because  fetal  death  occurs,  the 
placenta  becomes  a  foreign  body,  and  infection  is  inevitable. 

The  Prevention  of  Uterine  Rupture. — In  cases  where  the 
obstetrician  has  reason  to  believe  that  the  uterine  muscle  is 
abnormal  through  degeneration  or  infection,  especial  care 
must  be  exercised  in  all  intrauterine  manipulations.  Thus 
dilatation,  curetting  to  remove  the  products  of  early  gesta- 
tion, the  performance  of  version,  or  even  the  introduction  of 
the  hand  to  remove  the  placenta,  should  be  practised  with 
great  caution  in  infected  or  degenerated  cases. 

To  avoid  the  danger  of  uterine  rupture,  cases  where  un- 
favorable position  and  presentation  develop  should  not  be 
allowed  to  go  on  without  correction.  Thus  prolapse  of  the 
hand  with  transverse  position,  shoulder  presentation,  should 
be  removed  as  soon  as  possible.  Brow  presentation,  face 
with  chin  posterior,  transverse  position,  and  posterior  occiput, 


RUPTURE  OF  THE  UTERUS  411 

should  all  receive  prompt  attention.  In  cases  where  the 
contraction  ring  is  present  with  transverse  position  shoulder 
presentation,  or  other  oblique  and  complicated  positions,  the 
obstetrician  must  exercise  great  caution  in  attempting  de- 
livery. Version  in  any  form  is  especially  dangerous  in  pro- 
portion to  the  distention  of  the  lower  uterine  segment  and 
the  firm  contraction  of  its  upper  portion.  While  the  tetanic 
grasp  of  the  uterus  can  be  somewhat  relaxed  by  complete 
anesthesia,  sometimes  aided  by  morphia,  if  the  child  be  large 
this  cannot  be  relied  upon  to  permit  the  safe  performance 
of  version.  In  these  cases  embryotomy  must  be  chosen  to 
save  the  mother  at  the  expense  of  the  child.  In  prolapse  of 
the  arm  and  shoulder  the  fetal  body  forms  a  wedge  which  is 
forced  into  the  pelvic  brim,  making  descent  impossible. 
This  wedge  must  be  decomposed  by  amputating  the  shoulder, 
severing  the  clavicle,  or  by  performing  decapitation.  In 
some  cases  delivery  by  abdominal  section  becomes  necessary, 
and  is  much  safer  than  embryotomy,  followed  by  vaginal 
delivery. 

To  prevent  rupture  of  the  uterus  during  the  performance 
of  obstetric  operations  care  must  be  taken  to  apply  the  for- 
ceps properly  and  to  make  traction  invariably  in  the  axis  of 
the  birth  canal.  In  cases  where  the  head  is  evidently  large 
the  patient  should  not  be  allowed  to  continue  in  labor  without 
distinct  progress. 

Treatment. — In  the  presence  of  uterine  rupture  the  first 
indication  is  to  bring  the  patient  quickly  to  hospital.  As  a 
capital  operation  may  be  necessary,  the  surroundings  of  a 
hospital  are  absolutely  required  for  successful  treatment. 

An  examination  should  then  be  made  to  determine  the 
possibility  of  extracting  the  child  through  the  vagina  with- 
out enlarging  the  injury  to  the  uterus.  If  the  head  is  in  the 
pelvic  cavity  the  patient  should  be  anesthetized,  prepared 
for  abdominal  section,  and  the  child  delivered  carefully 
through  the  vagina.  If  it  is  found  that  the  effort  to  extract 
the  fetus  through  the  vagina  may  enlarge  the  rent  in  the 
uterus,  vaginal  delivery  must  not  be  attempted. 

If  it  is  possible  to  deliver  the  patient  through  the  vagina, 
and  the  placenta,  membranes  and  cord  are  thus  delivered, 
the  uterine  cavity  should  be  carefully  palpated  with  the 


412  MANUAL   OF   OBSTETRICS 

gloved  hand  to  determine  the  location  and  extent  of  the  rup- 
ture. If  this  be  found  longitudinal  or  through  the  contractile 
portion  of  the  uterus,  and  not  of  great  size,  and  if  it  has  not 
been  possible  to  transport  the  patient  to  hospital,  the  obstet- 
rician may  make  an  effort  to  save  the  uterus  and  to  avoid 
abdominal  section.  For  this  purpose  a  strip  of  iodoform 
gauze  nine  inches  wide  and  four  yards  long  should  be  carried 
with  the  fingers  of  the  gloved  hand  cautiously  through  the 
point  of  rupture  so  that  several  inches  of  the  gauze  project 
into  the  pelvic  or  abdominal  cavity.  The  amount  of  gauze 
carried  through  should  depend  upon  the  size  of  the  tear. 
The  remainder  should  be  used  to  tampon  the  uterine  cavity, 
the  whole  acting  as  an  antiseptic  drain.  The  patient  should 
be  given  strychnia  and  ergot  hypodermatically,  and  an  ice 
bag  placed  upon  the  abdomen.  Morphia  should  be  used 
sufficiently  to  quiet  pain,  the  bladder  should  be  emptied  by 
catheter,  and  the  digestive  organs  of  the  patient  should  re- 
ceive attention. 

If  it  is  not  possible  to  extract  the  fetus  through  the  vagina, 
or  if  after  such  extraction  a  large  transverse  rent  is  found,  the 
abdomen  must  be  opened  as  soon  as  possible. 

Unless  the  rent  is  small,  longitudinal,  and  situated  in  the 
expulsive  segment  only,  the  effort  to  save  the  uterus  by  su- 
turing its  lacerated  edges  cannot  be  successful. 

The  choice  lies  between  extirpation  of  the  uterus  or  hys- 
terectomy. Those  who  practice  extirpation  claim  that  by 
this  method  the  principal  danger  following  this  accident, 
namely,  septic  infection,  is  more  successfully  avoided.  Those 
who  practice  hysterectomy  avoid  the  dangers  of  total  ex- 
tirpation. 

If  much  of  the  uterine  contents  has  escaped  into  the  pel- 
vic or  abdominal  cavities,  drainage  should  be  employed 
after  hysterectomy.  If  septic  infection  has  evidently  de- 
veloped the  uterine  stump  should  be  left  outside  the  peri- 
toneal cavity,  either  by  the  Porro  operation,  with  the  clamp, 
or  by  stitching  the  stump  in  the  lower  end  of  the  abdominal 
incision.  Intravenous  saline  transfusion,  the  hypodermatic 
use  of  strychnia,  digitalin  and  atropin,  stimulating  enemata, 
artificial  warmth,  and  the  Faradic  current,  may  all  be  neces- 
sary. 


RUPTURE  OF  THE  UTERUS  413 

111  cases  where  unskilful  and  improper  efforts  at  vaginal  de- 
livery have  been  made  and  where  the  abdominal  cavity  is 
subsequently  opened,  the  obstetrician  may  find  partial  or 
complete  rupture  of  the  uterus  extending  along  the  bases  of 
one  or  both  broad  ligaments.  Considerable  extravasation  of 
blood  follows  this  accident,  and  it  is  sometimes  difficult  to 
control  the  source  of  the  bleeding. 

Prognosis. — The  fetus  is  inevitably  lost  in  rupture  of  the 
uterus.  The  mother's  chance  for  recovery  depends  upon  the 
extent  and  situation  of  the  rupture  and  the  prompt  use  of 
surgical  measures  for  her  life.  The  majority  of  cases  require 
abdominal  hysterectomy  as  soon  as  possible.  While  under 
antiseptic  precautions,  and  with  gauze  drainage,  the  mor- 
tality of  the  milder  cases  may  not  exceed  from  15  to  25  per 
cent,  in  severe  rupture  the  mortality  with  operation  may 
reach  30  and  40  per  cent. ;  without  operation  100  per  cent. 

Rupture  of  the  Uterus  Followed  by  Injury  to  the  Intestine. 
— In  cases  where  extensive  rupture  of  the  uterus  has  oc- 
curred, and  the  intestine  has  prolapsed,  a  considerable  por- 
tion of  the  bowel  has  been  removed  ignorantly  because  the 
attending  physician  did  not  recognize  the  situation.  While 
the  majority  of  these  cases  are  fatal,  the  effort  should  al- 
ways be  made  by  immediate  operation,  to  resect  the  torn 
intestine,  with  the  hope  of  saving  the  patient. 


PART  VI 
THE    FETUS 


CHAPTER  XXVII 
FETAL  PATHOLOGY 

Abnormalities  in  Size.— The  fetus  naturally  resembles 
in  size  the  parents,  when  both  are  similar  in  stature.  The 
height  of  the  mother  is  not  an  index  of  the  size  of  her  fetus, 
for  a  short  woman  with  broad  hips  and  shoulders  may  pro- 
duce a  large  child,  if  the  father  of  the  child  be  well  developed. 
The  lack  of  development  in  either  parent  may  be  transmitted 
to  the  fetus.  The  average  male  fetus  weighs  between  7  and 
8  Ibs.  at  birth;  the  average  female  fetus  between  6^2  and 
l]/2  Ibs.  at  birth.  Children  weighing  10  Ibs.  at  birth  are 
not  rare,  but  those  weighing  15  and  20  Ibs.  are  seldom  ac- 
curately reported.  The  stature  and  development  of  the 
parents  determine  that  of  the  fetus,  and  the  hygienic  condi- 
tions which  surround  the  mother  during  her  pregnancy.  In 
healthy  females,  where  there  are  several  children,  the  size 
of  the  children  tends  to  increase  after  the  second  child,  until 
the  mother  approaches  the  menopause.  The  occasional  ap- 
pearance of  dwarf  children  in  families  otherwise  of  average 
size  cannot  readily  be  explained.  These  individuals  are 
often  perfectly  formed,  but  are  usually  deficient  in  mental 
and  physical  vigor.  It  is  a  familiar  fact  that  male  children 
often  resemble  the  mother  and  female  children  the  father,  in 
physical  and  mental  characteristics. 

To  estimate  the  comparative  size  of  the  fetus  in  the  uterus, 
palpation  is  the  most  valuable  method.  This  should  be  ac- 
companied by  bimanual  vaginal  and  pelvic  examination,  the 

414 


MONSTROSITIES  415 

comparative  size  of  the  head  and  the  pelvis  being  ascertained 
by  pressing  the  head  downward  and  backward  into  the  pelvic 
brim.  The  length  of  the  fetus  may  be  measured  by  intro- 
ducing one  limb  of  the  pelvimeter  into  the  cervix  against  the 
head,  and  placing  the  other  on  the  abdomen  over  the  fundus 
of  the  uterus.  This  method  is  not  strictly  accurate,  but 
gives  information  of  value. 

In  estimating  the  size  of  the  fetal  cranium,  rhachitis  and 
hydrocephalus  must  be  eliminated  if  the  head  is  large.  In 
cases  where  it  is  necessary  to  obtain  accurate  knowledge  con- 
cerning the  size  of  the  fetal  cranium,  examination  by  the 
X-ray  is  often  satisfactory. 

MONSTROSITIES 

In  cases  where  the  mother  is  subjected  to  great  mechanical 
and  mental  disturbance  during  early  pregnancy,  malforma- 
tion may  result  in  deformity  of  the  embryo,  producing  a 
monster.  Where,  by  accident  or  design,  direct  violence  is 
applied  to  the  genital  tract  or  to  the  ovum,  malformation 
may  result.  It  has  constantly  been  supposed  that  shock 
and  fright  may  result  in  the  birth  of  monsters  resembling 
an  animal  which  may  have  frightened  the  mother,  or  some 
other  object  which  caused  great  mental  disturbance.  It  is 
probable  that  in  these  cases  some  other  cause  beside  the 
mental  disturbance  interfered  with  the  development  of  the 
ovum. 

Classification. — Monsters  are  commonly  divided  into  hemi- 
teratic,  heterotaxic,  hermaphroditic,  and  the  monstrous  fetus. 

By  hemiteratic,  we  understand  variations  in  the  volume, 
form,  color,  structure,  position,  number,  and  existence  of 
organs  normally  found  in  the  body.  Such  individuals  are 
the  dwarf,  the  giant,  a  fetus  with  diminutive  breasts  or  ex- 
cessive development  of  the  mammary  glands,  partial  de- 
velopment of  the  genital  tract,  deformed  pelvis,  Albinism, 
deficient  ossification  of  the  skeleton,  abnormalities  in  the 
bladder,  occlusion  of  the  rectum,  vulva  or  vagina,  hare-lip, 
cleft-palate,  absence  of  one  kidney  or  of  the  uterus,  double 
uterus,  or  additional  digits. 

The  fetus  resembles  the  normal  fetus  sufficiently  to  be 
recognized,  and  the  various  organs  can  be  identified. 


416 


The  heterotaxic  fetus  has  organs,  or  groups  of  organs  trans- 
posed— probably  caused  by  variation  in  the  arrangement 
of  the  different  layers  of  germinal  epithelium.  In  some  of 

these  cases  the  heart  is  found 
upon  the  right  side,  and  other 
important  organs  may  be  in  ab- 
normal positions. 

The  hermaphroditic  is  a  fetus 
containing  the  reproductive  or- 
gans of  both  sexes.  This  con- 
dition is  rarely  perfect,  but 
individuals  are  seen  in  whom 
a  portion  of  the  reproductive 
organs  of  both  sexes  is  pres- 
ent. 

The  monstrous  fetus,  or  mon- 
ster, is  so  distorted  that  it 
resembles  the  normal  human 
being  but  little.  Such  may  be 
single  or  composite — as  one  dis- 
torted individual,  or  two,  joined 
together. 

A  utositic  Monsters .  —  These 
deformed  fetuses  are  still  cap- 
able of  independent  existence. 
The  common  variety  is  ectro- 
melus,  in  which  the  limbs  are 
lacking  or  but  partly  developed. 
In  some  the  lower  limbs  are 
joined,  the  condition  being 
termed  symelus.  In  others 
there  is  failure  of  development 
in  the  brain,  the  cranium,  the 
eye,  or  other  organs  of  special 
senses. 

Omphalositic  Monsters. — These  monsters  have  such  de- 
formities or  abnormal  development  of  the  head,  the  thoracic 
viscera,  or  the  limbs,  that  make  their  life  impossible  when 
the  umbilical  cord  is  severed.  In  these  the  important  ner- 
vous centres  may  be  lacking,  or  the  heart  may  be  but  partly 


Fig.    153. — Autositic   monster 
(after  Hirst  and  Piersol). 


MONSTROSITIES  417 

developed,  or  the  blood  vessels  abnormal  in  their  arrange- 
ment. 

Composite  Monsters. — Composite  monsters  are  produced 
by  the  union  of  two  or  more  already  described.  Of  these,  the 
most  familiar  example  is  conjoined  twins.  The  Siamese 
twins,  two  males  connected  by  a  band  of  connective  tissue 


Fig.  Io4. — Omplialositio  monster  (after  Hirst  and  Piersol). 

containing  blood  vessels,  lived  to  be  adults,  and  were  fre- 
quently exhibited. 

Conjoined  twins  came  under  the  observation  of  the  writer 

some  years  ago.     They  were  joined  by  a  band  extending 

from  the  ensiform  cartilage  to  a  point  midway  between  the 

ensiform  and  the  symphysis  pubis  in  each  fetus.     There  was 

27 


418 


MANUAL    OF   OBSTETRICS 


one  common  umbilicus  containing  one  vein,  four  arteries,  and 
one  urachus.  The  urachus  bifurcated  after  entering  the 
umbilicus,  each  portion  passing  to  the  summit  of  the  bladder 
in  each  fetus.  The  livers  of  both  were  joined,  the  umbilical 
vein  passing  beneath  the  common  liver.  One  branch  of  the 
vein  passed  to  the  vena  cava  of  one  fetus;  the  other  passed 
through  one  portion  of  the  liver  in  the  connecting  band  to 
the  vena  cava  of  the  other  child.  There  were  other  abnormal 


Fig.  155. — Conjoined  twins  (after  Davis:  Treatise  on  Obstetrics). 

unions  between  various  important  organs  which  would  have 
rendered  the  separation  of  the  children  had  they  lived,  im- 
possible. 

Diagnosis  of  Monstrosities. — Palpation  and  vaginal  ex- 
amination as  labor  proceeds  will  often  make  possible  the 
diagnosis  of  monstrosities.  If  such  are  small  in  size  the  am- 
niotic  liquid  may  be  in  excess,  and  the  diagnosis  not  be  made 
until  the  child  is  born. 

In  conducting  labor  in  these  cases  the  clinical  rule  prevails 


MONSTROSITIES  419 

to  sacrifice  the  monster  in  the  interests  of  the  mother.  Em- 
bryotomy,  in  any  form  necessary,  is  the  treatment  indicated. 
Where  the  uterus  is  in  tetanic  contraction  and  rupture  is 
threatened,  delivery  by  abdominal  section  may  be  necessary 
in  the  interests  of  the  mother. 

Hydrocephalus. — In  external  hydrocephalus  the  cranium 
is  distended  by  fluid  external  to  the  brain  proper  between  the 


Fig.    156. — Hydrocephalus:    perforation  of  the  head  to  deliver 
(Liepmann). 

meninges  and  the  cranium.  In  internal  hydrocephalus  the 
fluid  accumulates  within  the  ventricles  of  the  brain.  These 
two  conditions  are  often  present  in  the  same  fetus. 

Abnormal  states  of  the  amnion  and  abnormal  conditions 
in  the  mother  producing  dropsy,  may  be  followed  by  hydro- 
cephalus. 


420  MANUAL    OF   OBSTETRICS 

The  diagnosis  is  made  by  the  great  size  of  the  fetal  head  on 
palpation  and  by  finding  the  head  smooth  and  elastic  on  vag- 
inal examination,  with  the  sutures  and  fontanelles  greatly 
increased  in  size  or  obliterated. 

Treatment. — The  effort  is  sometimes  made  to  evacuate 
the  fluid  by  tapping  the  spinal  column  at  the  base  of  the 
cranium.  If  this  can  readily  be  done  it  may  be  attempted, 
but  as  the  hydrocephalic  fetus  is  deficient  in  vitality,  no 
effort  should  be  made  to  save  its  life,  if  the  interests  of  the 
mother  demand  its  destruction. 

The  Management  of  Labor  where  the  Fetus  is  Excessively 
Developed. — If  there  is  no  reason  to  suspect  deformity,  but 
the  fetus  is  of  unusual  size  and  vigor,  and  engagement  and 
descent  do  not  occur,  the  mother  being  in  good  condition,  the 
child  should  be  delivered  by  abdominal  section.  If  the  sur- 
roundings make  this  unsafe,  or  if  there  is  reason  to  suspect 
malformation,  embryotomy  must  be  performed.  Where  the 
shoulders  are  excessive  in  size,  one  or  both  clavicles  may  be 
severed  by  strong  blunt-pointed  scissors,  the  operation  being 
known  as  cleidotomy. 

Fetal  Tumors. — The  birth  of  the  fetus  and  the  continu- 
ing of  its  life  may  be  rendered  impossible  by  tumors  in  the 
abdomen,  thorax,  cranium,  or  in  other  portions  of  the  body. 
Where  abdominal  tumors  are  present  the  fetal  abdomen 
should  be  opened  with  blunt-pointed  scissors,  the  contents 
of  the  tumor  evacuated,  and  delivery  effected  by  extraction. 
In  other  cases  embryotomy  must  be  performed  as  the  con- 
ditions permit. 

Polyhydramnios. — The  average  quantity  of  amniotic 
fluid  is  one  quart.  Where  disease  of  the  amnion  is  present, 
or  the  mother  suffers  from  disease  of  the  organs  of  digestion, 
or  circulation  fluid  may  accumulate  in  the  amniotic  sac,  poly- 
hydramnios  may  develop. 

Diagnosis. — In  these  cases  the  abdomen  increases  rapidly 
in  size,  especially  after  the  sixth  month.  Fetal  heart  sounds 
are  heard  faintly  or  not  at  all;  fetal  movements  are  often 
indistinguishable.  The  mother  suffers  from  increasing  ab- 
dominal pressure,  with  disturbance  of  respiration  and  heart 
action,  and  the  functions  of  the  bowels  and  bladder.  Sleep 


MOXSTROSITIES  421 

becomes  difficult  and  the  mother  cannot  move  because  of  the 
excessive  weight. 

Differential  Diagnosis. — Polyhydramnios  has  been  mis- 
taken for  ovarian  cyst,  abdominal  dropsy,  ectopic  gestation, 
multiple  pregnancy,  and  hydatid  mole. 

In  ovarian  cyst  there  is  a  history  of  comparatively  slow 
growth,  the  tumor  remains  unilateral,  pregnancy  may  or 
may  not  be  present,  and  the  characteristic  signs  of  pregnancy 
are  absent  or  may  be  obscured. 

In  abdominal  dropsy  the  fluid  gravitates  with  change  in  the 
posture  of  the  patient,  and  uterine  dullness  upon  percussion 
is  absent. 

Multiple  pregnancy  may  be  complicated  with  poly- 
hydramnios  when  the  diagnosis  is  difficult.  If  polyhy- 
dramnios  be  not  present,  two  heart  sounds  or  two  heads  can 
usually  be  made  out. 

In  ectopic  pregnancy  the  resistance  on  percussion  is  not  so 
much  fluid  as  solid,  and  the  history  indicates  ectopic  gesta- 
tion. 

In  hydatid  mole  the  tumor  is  not  fluid,  and  the  uterus  is 
usually  pear-shaped  in  contour,  and  does  not  give  the  sen- 
sation of  fluid  upon  percussion. 

Complications  Produced  by  Polyhydramnios. — In  these 
cases  the  mother  rarely  goes  to  full  term,  and  labor  is  brought 
on  by  tjie  over-distention  of  the  uterus.  Without  pain  a 
large  amount  of  fluid  is  discharged,  followed  by  a  period  of 
quiet,  and  the  rapid  birth  of  one  or  two  small  children. 
Collapse  of  the  cord,  abnormal  presentation  and  position,  re- 
laxation of  the  uterus,  and  hemorrhage,  may  result. 

The  Treatment  of  Polyhydramnios. — So  soon  as  it  is  evi- 
dent that  the  fluid  is  accumulating  steadily,  pregnancy  must 
end.  This  should  be  accomplished  by  rupturing  the  mem- 
branes, if  possible,  high  up  and  allowing  the  fluid  to  escape 
as  slowly  as  possible.  Abdominal  pressure  should  be  main- 
tained by  a  firm  many-tailed  bandage  closely  applied.  The 
expulsion  of  the  fetus  is  usually  sudden  in  these  cases,  and 
not  preceded  by  much  pain. 

Strychnia  and  ergot  should  be  given  afterward  and,  if 
necessary,  intra-uterine  tamponing  should  be  practised. 

As  the  fetus  is  ill-developed,  unusual  care  is  necessary  to 


422  MANUAL   OF   OBSTETRICS 

prolong  its  life.  In  many  of  these  cases  the  fetus  is  mal- 
formed and  does  not  long  survive. 

Oligohydramnion. — By  this  term  is  understood  a  lessened 
quantity  or  absence  of  amniotic  liquid.  This  is  usually  ac- 
companied by  malformation  of  the  fetus.  The  placenta  often 
shows  abnormalities  with  infarcts  and  sclerosis  of  its  vessels. 

The  diagnosis  is  usually  made  by  the  small  size  of  the 
uterine  tumor,  the  delay  in  dilatation  during  labor,  and  the 
deficient  quantity  of  fluid  which  escapes  when  the  membranes 
rupture. 

Fetal  Death.— Pathological  conditions  which  destroy  the 
placental  circulation,  or  which  occlude  the  umbilical  cord,  are 
the  most  common  causes  of  fetal  death.  The  mechanism 
of  this  death  is  asphyxia.  Where  the  cord  is  suddenly  oc- 
cluded, the  death  of  the  child  is  preceded  by  violent  move- 
ments, which  may  cause  the  mother  considerable  pain.  Fetal 
death  is  diagnosticated  by  the  cessation  of  fetal  heart  sounds 
and  movements,  and  by  the  diminution  in  size  of  the  uterus, 
caused  by  the  absorption  of  the  amniotic  liquid. 

This  condition  rarely  requires  treatment,  as  the  fetus  is 
expelled  spontaneously  sooner  or  later.  If  it  is  thought  best 
to  empty  the  uterus  the  rupture  of  the  membranes  is  usually 
sufficient. 

Fetal  Infection. — Abundant  clinical  observation  shows 
that  the  fetus  may  share  with  the  mother,  variola,  vaccinia, 
measles,  scarlet  fever,  typhoid,  malaria,  tuberculosis,  rheu- 
matism, septic  infection,  and  other  acute  infections. 

The  diagnosis  of  these  conditions  is  made  by  their  presence 
in  the  mother,  and  the  pathology  and  treatment  are  essen- 
tially those  of  the  disease  in  the  mother.  These  diseases  are 
transmitted  by  bacteria  which  make  their  way  through  the 
placenta  into  the  fetal  circulation. 

Fetal  Syphilis. — The  Spirochsete  may  attack  the  fetus, 
producing  characteristic  changes. 

The  Placenta. — The  syphilitic  placenta  is  larger  and  paler 
than  normal,  reddish  in  color  with  areas  of  grayish-white 
or  yellow.  It  is  abnormally  soft  and  often  friable.  It  is 
lighter  in  weight  than  the  healthy  subject. 

Microscopic  examination  shows  degeneration  of  the  villi, 
endarteritis  and  thrombosis.  The  circulation  of  the  placenta 


MONSTROSITIES 


423 


is  gradually  destroyed  by  the  disease.  The  vessels  of  the 
umbilical  cord  are  greatly  thickened;  the  amniotic  liquid  is 
often  in  excess,  and  syphilitic  lesions  in  the  heart  and  lungs 
may  be  present.  The  liver  shows  diffuse  interstitial  sclerosis, 
and  a  similar  process  is  present  in  the  lungs,  where  gumma 
are  sometimes  found.  The  glandular  organs  show  the 
characteristic  lesions  and  the  long  bones  exhibit  a  layer  of 
yellow  tissue  between  the  shaft  and  the  epiphysis.  This  is 


Fig.  157. — The  femur  of  a  syphilitic  fetus. 


especially  well  marked  in  the  femur.     Pemphigus  and  ich- 
thyosis  are  often  present. 

If  the  fetus  survives  its  birth  it  develops  a  red  coppery 
stauiing  about  the  anus  and  genital  organs,  an  earthy,  gray- 
colored  complexion,  redness  of  the  mucous  membranes, 
chronic  nasal  catarrh,  and  a  wasted  and  flabby  condition  of 
the  tissues.  The  bones  become  altered  and  softened  and 
the  contour  of  the  fetal  cranium  may  be  greatly  changed. 
The  nervous  system  suffers  proportionately. 


424  MANUAL   OF   OBSTETRICS 

Diagnosis. — The  diagnosis  of  syphilis  in  the  living  fetus  is 
usually  made  by  the  condition  of  the  skin,  the  malnutrition 
present,  and  the  characteristic  general  appearance  of  the 
child.  The  Wassermann  reaction  is  usually  positive.  If  the 
fetus  comes  to  autopsy  the  characteristic  lesions  are  usually 
evident. 

Colles'  Law. — By  clinical  observation,  Colles  was  led  to 
enunciate  the  belief  that  an  apparently  healthy  mother  giv- 
ing birth  to  a  syphilitic  child  may  nurse  that  child  without 
incurring  a  chancre  upon  the  breast;  in  other  words,  she 
seems  partially  or  wholly  immune.  While  there  are  excep- 
tions to  this  rule,  it  is  usually  true. 

Mortality  and  Morbidity. — Extensive  observations  show 
that  when  syphilitic  infection  occurs  in  the  mother  before 
conception,  the  mortality  of  the  fetus  born  afterward  is  65 
per  cent.,  the  morbidity  70  per  cent.  When  conception  pre- 
ceded infection,  the  fetal  mortality  was  39  per  cent.,  the  mor- 
bidity 72  per  cent.  When  specific  infection  and  conception 
occurred  simultaneously,  the  mortality  of  the  fetus  was  75 
per  cent.,  the  morbidity  91  per  cent.  The  mortality  is  mod- 
ified somewhat  by  the  transmitter.  Where  the  father  alone 
is  syphilitic,  the  fetal  mortality  is  28  per  cent.,  the  morbidity 
37  per  cent.  If  the  mother  alone  be  syphilitic,  the  fetal 
mortality  is  60  per  cent.,  the  morbidity  80  per  cent.  Where 
both  father  and  mother  are  syphilitic,  the  fetal  death-rate 
is  68.5  per  cent.,  the  morbidity  92  per  cent. 

Treatment. — The  treatment  of  syphilis  in  the  fetus  is  the 
treatment  of  the  mother.  Salvarsan,  mercury,  iodide  of 
potassium,  tonics,  careful  feeding,  and  good  hygiene,  are  all 
indicated. 

Fetal  Tuberculosis. — The  tubercle  bacillus  may  pene- 
trate the  placenta  and  attack  the  fetus.  The  lesions  which 
it  produces  correspond  closely  to  those  which  are  found  in  the 
adult  person,  the  tubercle  bacilli  being  usually  demonstrable 
in  the  placenta. 

While  fetal  death  from  tuberculosis  is  rare,  the  disease 
may  develop  actively  at  any  time  after  birth. 

Alcoholism. — The  use  of  alcohol  on  the  part  of  the  parents 
is  one  of  the  most  potent  causes  of  impaired  development 
and  death  in  the  fetus.  The  injurious  effects  of  alcohol  are 


PLATE  II 


Gonorrhea!  infection  in  the  mouth  of  the  fetus  at  birth  (Rosinski). 


MONSTROSITIES  425 

seen  especially  in  the  nervous  >y>tem  of  the  child,  producing 
idiocy,  epilepsy,  imbecility,  hysteria,  and  insanity. 

The  statistics  of  the  asylum  show  that  at  least  40  per  cent, 
of  these  cases  had  drunken  parents.  A  fetus  born  of  drunken 
parents  is  deficient  in  development,  badly  nourished,  and 
falls  a  ready  prey  to  acute  infection. 

Gonorrhea. — Gonorrhea  in  the  mother  may  infect  the 
fetus  by  the  passage  of  the  gonococcus  through  the  mem- 
branes. The  fetus  has  been  born  with  gonorrheal  patches 
on  the  tongue  and  upon  the  mucous  membranes  of  the  mouth. 
Gonorrheal  ophthalmia  may  also  be  present  at  birth.  In 
these  cases  nothing  can  be  done  in  treatment  before  the  birth 
of  the  child,  ami  after  birth  appropriate  measures  are  usually 
successful. 

The  Effect  of  Poisons  upon  the  Fetus. — Lead,  mercury, 
phosphorous,  tobacco,  chloroform,  ether,  opium,  and  poison- 
ous gases,  all  exert  a  fatal  and  unfavorable  influence  upon  the 
fetus.  For  this  reason  pregnant  women  should  not  enter 
occupations  where  they  are  exposed  to  poisonous  fumes,  or 
to  the  absorption  of  poisons.  Poisonous  drugs  should  be 
used  with  great  caution  during  pregnancy. 

Abnormalities  of  the  Skin. — Areas  of  dilatated  blood- 
vessels upon  the  skin  produce  the  characteristic  red  patches 
known  as  birth-marks.  They  may  occur  on  any  portion  of 
the  body  and  are  sometimes  accompanied  by  enlargement  of 
the  thymus  gland.  If  the  child  survives  and  grows  vigorous, 
these  patches  may  spontaneously  disappear.  In  other  cases 
they  tend  to  become  larger,  and  must  be  treated  by  the  de- 
struction of  the  vessels,  by  electricity,  radium,  or  some  other 
escharotic  method. 

In  fetal  ichthyosis  the  body  is  covered  with  thick  horny 
yellow  plates,  the  surface  beneath  being  reddish  or  bluish 
in  color.  The  epidermis  is  greatly  hardened  and  thickened, 
the  hands  and  feet  deformed,  resembling  birds'  claws.  The 
vitality  of  the  fetus  is  greatly  impaired  and  it  rarely  survives 
its  birth  for  a  long  time. 

Disease  of  the  Fetal  Skeleton. — Where  the  mother  is 
badly  nourished,  the  fetus  may  be  rhachitic.  This  is  of 
practical  interest  to  the  obstetrician,  as  the  fetal  cranium  is 
broader,  thicker,  and  more  dense  than  the  normal  fetal  cran- 


426  MANUAL    OF   OBSTETRICS 

ium.  The  fetal  head  does  not  mould  during  labor,  and  if  the 
mother's  pelvis  be  contracted,  or  there  be  considerable  dis- 
proportion between  mother  and  child,  the  occurrence  of 
rhachitis  in  the  fetal  cranium  may  make  the  birth  of  a  living 
child  impossible. 

Failure  of  development  in  the  fetal  bones  may  occur,  giv- 
ing rise  to  the  belief  that  the  bones  have  been  spontaneously 
fractured  or  amputated  in  the  uterus.  In  most  cases  mal- 
development  is  present  and  not  amputation. 

Diseases  of  the  Fetal  Urinary  and  Genital  Organs. — 
Chronic  nephritis  and  distention  of  the  fetal  urinary  bladder 
and  mal-formations  of  the  bladder,  are  observed.  The  diag- 
nosis of  such  conditions  is  rarely  possible  before  labor,  and 
after  labor  the  vitality  of  the  fetus  is  often  so  impaired  that 
its  life  does  not  long  persist. 

Double  uterus  and  vagina,  or  deficient  development  in  the 
genital  organs  of  the  fetus  is  not  rare.  In  these  cases  treat- 
ment is  unnecessary,  and  the  child  should  be  allowed  to  grow 
to  puberty  before  operative  interference  is  indicated. 

Imperforate  Anus  and  Urethra. — Children  should  be  ex- 
amined at  birth  to  detect  these  conditions.  Where  the  anus 
is  imperforate,  malformations  of  the  bowel  are  present,  and 
it  may  be  found  that  the  rectum  is  wanting  and  that  the  bowel 
terminates  several  inches  from  the  usual  location  of  the  anus. 
An  artificial  anus  is  sometimes  made  in  these  cases,  if  the 
child  is  vigorous  and  otherwise  well  developed. 

Imperforate  urethra  in  the  male  may  result  from  tight 
phimosis.  In  these  cases  the  prepuce  must  be  stretched  or 
circumcision  immediately  performed.  Occlusion  of  the  ure- 
thra in  the  female  fetus  is  not  observed. 

Abnormalities  in  the  Fetal  Adnexa. — An  excessively  long 
umbilical  cord  may  complicate  fetal  life  through  coiling  about 
the  fetal  body.  The  most  frequent  site  of  this  condition  is 
the  fetal  neck,  and  if  traction  be  made  asphyxia  may  be  the 
result.  When  the  head  is  born,  the  obstetrician  must  al- 
ways pass  the  fingers  up  to  the  neck  to  determine  the  pres- 
ence or  absence  of  coils  of  the  cord.  Should  the  cord  be 
tightly  coiled  it  must  at  once  be  clamped  and  cut  and  the 
fetus  extracted  as  rapidly  as  is  safe.  Occasionally  the  cord 
may  be  pulled  down  gently  and  slipped  over  the  fetal  head 
and  thus  loosened. 


TREATMENT  OF  FETAL  DEVELOPMENT        427 

Although  the  cord  may  be  normal  in  length  the  mother  may 
fall  during  the  latter  weeks  of  pregnancy,  when  the  strain 
and  shock  of  falling  may  cause  violent  fetal  movement  which 
coils  the  cord  about  its  neck.  The  gradual  occlusion  of  the 
cord  and  fetal  death  may  result. 

An  abnormally  short  cord  may  be  a  source  of  danger  to 
the  child  during  labor,  as  it  will  produce  traction  upon  the 
placenta  and  may  partly  detach  it,  causing  hemorrhage  and 
fetal  death.  Should  there  be  evidence  of  this  during  labor 
the  child  must  be  extracted  as  rapidly  as  possible  and  the 
uterus  promptly  emptied. 

Rupture  of  the  Umbilical  Cord  During  Labor. — Occasion- 
ally in  precipitate  birth  where  the  child  falls  from  the  body 
of  the  mother,  the  umbilical  cord  may  be  ruptured.  Dan- 
gerous hemorrhage  rarely  results,  as  the  vessels  usually  re- 
tract and  stop  bleeding.  Should  the  force  be  sufficient  to 
separate  the  placenta  from  the  uterine  wall,  the  fetus  may 
die  as  a  result  of  the  hemorrhage. 

Fetal  death  occasionally  results  through  the  rupture  of 
veins  of  the  placenta  or  some  of  the  placental  sinuses  through 
diseased  conditions  of  the  vessels,  or  violence  occurring  dur- 
ing pregnancy.  This  condition  must  be  inferred  by  the  vio- 
lent movements  of  the  child  as  the  hemorrhage  causes 
asphyxia  to  develop. 

THE  TREATMENT  OF  FETAL  DEVELOPMENT  BY  DIET  AND 

HYGIENE 

Where  disproportion  has  developed  in  previous  preg- 
nancies between  mother  and  child,  or  the  mother's  pelvis  is 
slightly  contracted,  the  effort  is  sometimes  made  to  lessen 
fetal  size  by  the  mother's  diet.  Diminution  in  the  quantity 
of  the  mother's  food  is  not  followed  by  corresponding  diminu- 
tion in  the  size  of  the  fetus  because  the  fetus  lives  at  the 
expense  of  the  mother  as  a  parasite.  By  excluding  as  much 
as  possible  water,  soups,  potatoes,  puddings,  sugar,  and  malt 
beverages,  it  has  been  found  possible  to  lessen  the  size  and 
development  of  the  child  without  producing  malformation. 
A  limited  quantity  of  tea  or  coffee  is  allowed,  and  a  limited 
quantity  of  light  wine,  if  desired.  The  essentials  of  the  diet  con- 
sist of  meat,  eggs,  fish,  green  vegetables,  salads  and  cheese. 


CHAPTER  XXVIII 
INJURIES  TO  THE  FETUS  IN  LABOR 

Birth  Pressure. — The  most  common  injury  which  the 
fetus  sustains  during  labor  is  birth  pressure.  While  this  is 
present  in  all  spontaneous  parturitions,  where  the  fetus  ad- 
vances and  recedes  normally  the  pressure  is  intermittent 
and  the  circulation  in  the  fetus  adjusts  itself  to  the  altered 
conditions.  Where  the  fetus  is  forced  down  strongly  upon 
the  pelvic  floor  in  the  bony  pelvis  and  remains  impacted,  the 
pressure  is  constant  and  injury  results. 

Birth  pressure  may  cause  rupture  of  cerebral  vessels  with 
hemorrhage,  or  rupture  of  small  vessels  in  any  of  the  large 
organs  of  the  fetal  body,  producing  parenchymatous  bleeding. 
Thus  the  fetus  may  suffer  from  cerebral  or  pulmonary  apo- 
plexy, or  from  bleeding  into  the  substance  of  the  liver,  spleen 
or  other  abdominal  organs.  Birth  pressure  may  also  in- 
terfere with  the  circulation  in  the  umbilical  cord,  thus 
depriving  the  fetus  of  oxygenated  blood  and  causing  involun- 
tary respiratory  movements.  If  the  fetus  inspires  mucus 
and  bacteria  from  the  birth  canal,  inspiration  pneumonia 
may  result.  Fetal  death  is  a  common  effect  of  birth  pres- 
sure through  hemorrhage,  inspiration  pneumonia,  or  in  ex- 
treme cases  from  laceration  of  the  cerebral  substance  or  of 
the  membranes  covering  the  brain. 

Injurious  birth  pressure  may  be  inferred  when,  after  the 
child  is  delivered,  it  breathes  feebly  and  irregularly,  with 
a  constant  moaning  or  shrieking  cry,  and  when  the  tempera- 
ture rises  steadily  and  rapidly  after  delivery.  If  hemor- 
rhage is  severe  the  child  breathes  feebly,  the  heart  action  is 
poor,  and  death  soon  follows.  Where  the  child  survives 
birth  pressure,  some  permanent  injury  to  the  nervous  system 
may  develop  through  hemorrhage  into  the  substance  of  the 
brain,  or  injury  to  some  other  portion  of  the  nervous  system. 

428 


PLATE  III 


Hemorrhage  into  the  brain,  kidney,  spleen,  and  liver  from  birth 
pressure  (Spencer). 


INJURIES    TO   THE   FETUS   IN   LABOR  429 

Asphyxia.-  Fetal  asphyxia  is  usually  divided  into  two 
classes — pallid  and  livid.  This  classification  is  based  upon 
the  color  of  the  fetal  face  and  skin  after  birth,  which  is  dark 
reddish-blue  in  livid  asphyxia,  and  pale  or  corpse-like  in 
pallid  asphyxia.  Carbon  dioxid  poisoning  is  the  essential 
condition  in  both.  In  livid  asphyxia,  the  poisoning  is  in  the 
first  stage,  and  the  child,  though  blue  and  dusky  in  the  face, 
has  a  distinct  heart  beat  and  may  make  feeble  efforts  at 
respiration.  Its  reflexes  are  still  present,  and  if  the  finger 
be  moistened  with  salt  water  or  with  whiskey  and  intro- 
duced into  the  mouth  the  child  will  usually  suck  on  the  finger. 
If  the  action  of  the  heart  is  maintained,  and  air  is  brought 
into  the  lungs,  the  majority  of  these  cases  will  recover. 

In  pale  or  pallid  asphyxia,  the  carbon-dioxid  poisoning 
has  gone  so  far  that  the  vital  centres  are  paralyzed  and  the 
action  of  the  heart  is  almost  completely  suspended.  Many 
of  these  cases  are  beyond  treatment  when  the  child  is  born, 
and  react  but  feebly  to  any  sort  of  stimulation.  In  many 
cases  the  reflexes  are  absent,  the  sphincters  relaxed,  the  heart 
beat  is  exceedingly  feeble,  or  cannot  be  detected. 

The  Causes  of  Asphyxia. — Whatever  interferes  with  the 
circulation  of  the  umbilical  cord  or  deprives  the  placenta 
of  oxygenated  blood  will  produce  asphyxia — so  coiling  of  the 
cord,  occlusion  of  the  cord  by  pressure,  and  separation  of  the 
placenta  from  the  uterine  wall,  followed  by  hemorrhage,  pro- 
duce asphyxia. 

To  recognize  the  accident,  one  may  sometimes  diagnosticate 
the  coiling  of  the  cord  by  detecting  a  hissing  sound  slower 
than  the  fetal  heart,  and  more  rapid  than  the  mother's  arte- 
rial heartbeat  over  the  fetal  body  near  the  head.  In  other 
cases,  violent  movements  of  the  fetus,  following  a  blow 
or  fall  in  the  mother,  may  lead  the  obstetrician  to  fear  that 
traction  is  being  made  upon  the  cord. 

In  these  cases  delivery  should  be  accomplished  as  rapidly 
as  the  safety  of  the  mother  will  permit.  The  same  is  true 
concerning  asphyxia  from  hemorrhage  following  placental 
separation.  In  placental  pravia  and  accidental  separation 
of  the  normally  implanted  placenta,  the  fetal  mortality  is 
high  from  asphyxia.  The  necessity  for  prompt  delivery  is  as 
urgent  in  these  cases  as  in  cases  where  the  cord  is  occluded. 


430  MANUAL   OF   OBSTETRICS 

The  Treatment  of  Asphyxia. — All  cases  of  labor  should  be 
so  conducted  that  the  obstetrician  must  prepare  to  treat 
asphyxia  as  soon  as  the  child  is  born.  Where  this  condition 
develops,  the  child  should  be  firmly  grasped  by  the  legs  and 
thighs  and  held  head  downward  while  the  forehead  is  sup- 
ported by  one  hand  of  the  obstetrician.  The  nurse  or  helper 
should  then  wipe  out  the  child's  mouth  gently  but  thoroughly, 
with  sterile  linen.  The  child  should  then  be  graspecl  by  the 
thighs  with  one  hand  of  the  obstetrician  while  the  other  is 
placed  across  the  back,  the  thumb  and  finger  resting  upon  the 
anterior  surface  of  the  chest.  The  child's  body  should  then 
be  folded  and  unfolded  gently  but  completely,  the  time  oc- 
cupied in  counting  six  being  sufficient  for  each  motion.  At 
intervals  this  motion  should  be  stopped,  the  child's  mouth 
again  cleansed,  and  the  folding  and  unfolding  repeated.  If 
there  is  any  sign  of  respiration  the  child  should  be  placed  in 
a  warm  bath  in  which  mustard  has  been  stirred,  and  rubbed 
gently  but  quickly  until  the  surface  of  the  body  is  quite  red. 
If  a  few  drops  of  cold  water  be  dashed  upon  the  chest  this 
will  often  excite  respiration.  If  breathing  does  not  follow, 
the  child  should  be  quickly  dried  and  the  folding  and  un- 
folding again  repeated.  So  long  as  heart  action  can  be 
detected  the  attempt  to  establish  respiration  should  not  be 
abandoned.  A  hypodermatic  injection  of  strychnia,  -5-^-5-  gr., 
digitalin  -3-5-5-  gr.,  and  atropin  3-^  gr.,  may  be  given  together. 

At  intervals  the  child  should  be  laid  upon  a  soft  blanket 
or  pillow,  upon  its  right  side  with  its  head  slightly  lower  than 
the  feet,  and  opportunity  be  given  for  spontaneous  breathing. 

Cases  of  livid  asphyxia  usually  clear  up  promptly  with 
this  treatment,  and  respiration  becomes  normal. 

If  the  pulmotor  be  available  this  may  be  used,  and  is  often 
successful  when  other  methods  fail.  The  swinging  method 
of  Schultze,  and  the  treatment  usually  adopted  for  the 
drowned,  are  also  available  and  are  sometimes  useful.  By 
Schultze's  method  air  will  be  forced  into  the  lungs,  but  this 
will  not  necessarily  cause  the  heart  to  beat  nor  establish 
normal  breathing. 

Pallid  Asphyxia. — When  the  circulation  of  the  newborn 
is  reduced  to  so  low  a  point  that  the  child  is  pale,  limp,  and 
without  apparent  signs  of  life,  the  condition  is  known  as 


INJURIES  TO  THE  FETUS  IN  LABOR         431 

pallid  asphyxia.  In  these  cases  the  effort  of  the  obstetrician 
should  be  directed  toward  rousing  the  circulation  and  then 
to  establishing  respiration. 

To  stimulate  the  action  of  the  heart,  -5^-$  grain  of  strychnia, 
3-5-5-  grain  of  digitalin,  and  -5-5-5-  grain  of  atropin,  may  be  given 
hypodermat  ic  ally . 

Artificial  warmth  should  be  applied,  and  the  child's  body 
gently  rubbed  from  the  limbs  toward  the  heart.  The  in- 
terrupted Faradic  current  is  of  especial  value.  Two  drachms 
of  whiskey  in  one  ounce  of  warm  water  may  be  injected  into 
the  rectum,  or  the  lower  bowel  may  be  washed  out  by  a  copi- 
ous irrigation  of  warm  salt  solution.  The  child  should  be 
kept  with  the  head  lower  than  the  feet,  and  the  pulmotor 
may  be  used  to  advantage  to  fill  and  empty  the  lungs.  Coun- 
ter-irritation over  the  heart  by  spirits  of  camphor,  mustard 
and  water,  spirits  of  turpentine,  or  a  flannel  wrung  out  of 
hot  water  sprinkled  with  alcohol,  may  be  used. 

If  the  pulmotor  is  not  available,  the  child  may  be  wrapped 
in  a  hot  towel,  or  a  piece  of  hot  flannel,  held  with  the  head 
downward,  and  folded  and  unfolded  by  the  method  described 
in  the  treatment  of  livid  asphyxia.  When  the  child's  body 
is  folded  together,  the  abdominal  contents  are  pushed  up- 
ward against  the  diaphragm  and  the  thoracic  contents  are 
pushed  downward.  The  heart  and  its  great  vessels  are  thus 
compressed  between  the  two,  and  the  blood  is  forced  out  of 
the  great  veins.  When  the  child's  body  is  unfolded,  the  ab- 
dominal viscera  descend,  pressure  is  removed  from  the  thorax, 
and  the  blood  is  given  an  opportunity  to  flow  into  the  ab- 
dominal and  thoracic  viscera. 

This  simple  method  is  thus  of  great  advantage  not  only  in 
establishing  respiration,  but  in  stimulating  the  action  of  the 
heart. 

An  indication  of  the  success  of  treatment  may  be  found  in 
the  presence  of  reflexes.  If  the  child's  pupils  remain  abso- 
lutely insensible  to  a  small  electric  light,  if  the  surface  of  the 
body  remains  persistently  white  and  cold,  if  the  child's 
muscles  are  completely  limp,  and  if  the  finger  dipped  in  salt 
water  or  in  whiskey  and  passed  down  the  throat  rouses  no  re- 
flex contraction  of  the  muscles  of  the  pharynx,  the  death 
of  the  child  has  occurred.  If,  however,  there  is  the  slightest 


432  MANUAL   OF   OBSTETRICS 

response  to  these  tests,  the  effort  to  resuscitate  must  be  con- 
tinued. At  the  moment  of  death  the  sphincters  often  relax 
and  meconium  is  frequently  discharged  from  the  bowel. 

The  Secondary  Dangers  of  Asphyxia. — Although  the  new- 
born child  may  temporarily  recover  from  asphyxia,  it  is  more 
liable  than  others  to  inspiration  pneumonia  and  to  apoplexy 
of  the  lung,  or  injury  to  some  of  the  thoracic  or  abdominal 
viscera.  Violent  efforts  at  resuscitation  often  injure  the 
fetus  fatally.  In  unskilful  hands  Schultze's  method  of  swing- 
ing the  child  has  produced  serious  injury. 

Schultze's  Method. — To  perform  this  method  of  resuscita- 
tion, the  operator  stands  grasping  the  naked  body  of  the 
child,  with  the  thumbs  upon  the  anterior  surface  of  the  thorax 
and  the  fingers  upon  the  posterior  surface  just  below  the 
scapulae.  The  head  is  steadied  between  the  upper  portion  of 
the  hands  and  wrists  of  the  operator.  Bending  forward,  the 
operator  then  raises  the  body  of  the  child  over  his  head  and 
shoulder  with  a  long  swinging  motion.  Reversing  this  mo- 
tion, the  body  of  the  child  is  swung  outward  and  downward 
until  its  feet  are  within  a  short  distance  of  the  floor.  These 
motions  are  repeated  with  intervals  of  one  or  two  minutes. 
When  the  child's  body  is  swung  backward  over  the  shoulder 
of  the  operator  the  lower  extremities  are  bent  upward  toward 
the  abdomen,  the  abdominal  contents  are  pressed  against 
the  diaphragm,  the  diaphragm  is  forced  upward,  and  the 
lungs  are  compressed  with  the  heart,  forcing  air  out  of  the 
lungs.  When  the  child  is  swung  outward  and  downward 
toward  the  floor,  the  force  of  gravity  carries  the  abdominal 
viscera  downward,  the  diaphragm  descends,  and  air  rushes 
into  the  mouth  and  nose  and  into  the  trachea. 

In  most  cases  this  method  is  successful  in  forcing  air  into 
the  lungs.  It  does  not,  however,  stimulate  the  heart,  and 
if  violently  or  unskilfully  performed  it  has  caused  injury 
to  the  lungs  and  occasionally  to  the  bones  of  the  thoracic 
region. 

Injuries  to  the  Fetus  during  Labor. — In  addition  to  the 
general  results  of  birth  pressure  already  described,  the  fetal 
bones  may  be  fractured  during  labor,  dislocation  or  sprain 
of  the  joints  may  occur,  and  various  portions  of  the  fetal 
body  may  be  injured  by  direct  violence. 


INJURIES    TO    THK    FETUS    IN    LABOR  433 

Fractures  of  the  Cranium.  When  the  pelvis  is  consider- 
ably contracted  and  the  fetus  is  brought  forcibly  through  the 
pelvis,  fracture  of  the  cranial  bones  is  not  uncommon.  The 
region  of  the  parietal  bones  is  most  often  the  site  of  fracture, 
as  in  difficult  labor  the  head  often  turns  transversely  at  the 
pelvic  brim,  and  thus  the  parietal  bone  may  be  brought  forc- 
ibly against  the  promontory  of  the  sacrum.  Such  fractures 
may  be  accompanied  by  depression  ol  the  bone,  or  this  com- 
plication may  not  be  present.  If  the  fracture  is  severe,  the 
meningeal  artery  beneath  the  parietal  bone  may  be  wounded, 


Fig.  158. — Cephalhematoma. 

or  the  veins  and  sinuses  of  the  brain  may  be  injured.  Intra- 
cranial  hemorrhage  will  result,  often  with  fatal  issue.  The 
cranial  bones  may  also  be  fractured  by  the  violence  and  un- 
skilful use  of  forceps.  When  the  head  is  transversely  in  the 
pelvic  brim  and  the  forceps  is  applied  over  the  face  and  oc- 
ciput, or  when  the  head  is  oblique  in  the  pelvic  brim  and  the 
forceps  is  not  applied  to  the  sides  of  the  head,  severe  pressure 
and  forcible  traction  may  often  cause  fracture.  Such  frac- 
tures are  accompanied  by  the  formation  of  a  deep  groove  in 
the  soft  parts,  extending  often  to  the  periosteum.  Fractures 
28 


434  MANUAL    OF   OBSTETRICS 

of  the  base  of  the  fetal  cranium  are  observed  in  cases  of  diffi- 
cult labor  where  considerable  force  is  used  in  applying  for- 
ceps, or  where  the  child's  head  is  brought  forcibly  through  a 
contracted  pelvis  in  breech  extraction. 

In  many  cases  complete  fracture  of  the  cranial  bones  can- 
not be  demonstrated. 

The  bones  of  the  face  and  the  cartilage  of  the  nose  are 
occasionally  injured  where  violent  and  unskilful  attempts 
have  been  made  to  deliver  by  forceps. 

The  Signs  and  Symptoms  of  Cranial  Fracture. — Severe  and 
even  fatal  injury  to  the  brain  of  the  newborn  infant  may  oc- 
cur with  but  little  visible  indication  of  the  severity  of  the 
fracture.  The  only  evidence  of  serious  complication  in  these 
cases  may  be  a  groove  in  the  soft  parts  marking  the  pressure 
of  the  edge  of  the  forceps  blade. 

In  these  cases  the  diagnosis  of  cerebral  injury  must  be 
made  by  the  symptoms.  The  child  is  fretful  or  stuporous 
and  quiet,  the  pupils  reacting  but  sluggishly  to  light.  The 
child  often  has  a  peculiar  and  almost  incessant  cry  or  moan, 
the  temperature  is  somewhat  elevated,  and  the  child's  heart 
action  feeble  and  irregular.  By  palpating  the  cranium,  de- 
pression of  the  cranial  bone  can  be  made  out. 

Treatment. — The  treatment  of  depression,  or  depression 
and  fracture  of  the  cranial  bone  in  the  newborn,  consists  in 
elevating  the  bone  to  its  normal  level.  This  may  not  re- 
quire incision  as  in  the  adult,  but  a  sharp  hook  may  be  intro- 
duced through  the  scalp,  if  it  be  not  swollen,  into  the  bone, 
and  the  bone  gently  raised  by  traction  upon  the  hook.  Other 
operators  prefer  to  cut  down  upon  the  bone.  Where  the 
pressure  has  been  sufficient  to  cause  the  child's  symptoms, 
elevation  of  the  bone  will  be  followed  by  their  disappearance 
and  the  gradual  recovery  of  the  child.  In  extreme  cases, 
where  the  bone  has  been  fractured,  its  fragments  may  have 
been  driven  into  the  cerebral  substance,  occasioning  fatal 
injury. 

Permanent  injury  to  the  nervous  system  may  result  from 
compression  or  fracture  of  the  fetal  cranium.  Areas  of 
softening  and  degeneration  in  the  fetal  brain  may  develop, 
and  the  child  may  show  evidence  of  injury  to  the  cerebral 
cortex  or  deeper  tissues. 


INJURIES   TO   THE   FETUS   IN   LABOR 


435 


Fractures  of  the  Fetal  Clavicle. — Where  the  shoulders  are 
excessively  large  and  delivery  is  effected  with  considerable 
violence,  one  or  both  of  the  clavicles  may  be  fractured.  As 
this  is  rarely  compound  the  accident  is  not  often  serious.  To 


Fig.  159. — Fracture  of  both  clavicles  treated  by  bandaging  the  infant 
upon  a  thickly  padded  board. 


secure  good  approximation  is  difficult,  if  the  child  be  treated 
by  the  bandage  and  pad  often  used  for  adults.  The  most 
efficient  treatment  under  these  conditions  is  to  bandage 
the  child  firmly  upon  its  back  upon  a  firm  pillow  or  upon  a 


436  MANUAL   OF   OBSTETRICS 

broad  splint,  so  that  the  fragments  are  kept  in  good  apposi- 
tion. By  using  broad  gauze  bandages  in  the  Figure-of-8, 
the  child's  body  can  be  kept  closely  applied  to  the  support, 
and  thus  union  secured. 

Fractures  of  the  Humerus. — Where  the  arms  become  ex- 
tended during  breech  labor,  or  where  an  anomalous  trans- 
verse position  is  present,  in  which  the  arms  must  be  dis- 
lodged, the  humerus  may  be  broken.  The  usual  site  of  this 
fracture  is  at  the  junction  of  the  upper  third  and  the  lower 
two-thirds.  This  fracture  is  usually  caused  by  applying 
force  to  the  shaft  of  the  bone  instead  of  passing  the  fingers 
down  the  arm  to  the  elbow,  to  flex  the  entire  upper  extremity 
and  to  bring  down  the  arm  without  fracture. 


Fig.  160. — Greenstick  fracture  of  humerus  following  difficult  labor; 
breech  extraction. 


Such  fracture  is  usually  incomplete  or  green-stick  in  variety. 
There  may  not  be  typical  crepitation,  but  the  fragments  can 
be  felt  to  move,  and  there  is  more  or  less  impaired  motion. 

Treatment. — In  selecting  splints  for  the  use  of  the  newborn, 
care  must  be  taken  that  heavy  material  is  not  chosen,  and 
that  in  applying  the  splint  excessive  pressure  is  not  exerted. 
Pasteboard  dipped  in  hot  water  can  be  readily  moulded  to 
fit  the  arm  or  shoulder  of  the  newborn,  and  this  with  carded 
wool  padding  and  a  gauze  bandage,  makes  a  comfortable 
and  safe  application.  The  splint  must  be  frequently  re- 
moved and  the  bone  examined  by  palpation  to  determine  the 
progress  of  recovery. 

It  is  difficult  to  confine  the  arm  of  the  newborn  unless  it  be 


INJURIES   TO   THE   FETUS   IN    LABOR 


437 


bandaged  to  the  side  and  retained  in  position  by  broad  band- 
ages passing  completely  about  the  body.  It  is  usually  best 
to  allow  the  child  to  move  the  hands  and  fingers  freely. 

Fractures  of  the  Femur.— The  femur  is  not  often  broken 
in  children,  and  like  the  humerus  its  most  usual  site  of  frac- 
ture is  in  the  upper  portion  of  the  shaft. 

Fractures  of  other  Bones. — In  cases  of  extreme  violence  in 
delivery  the  child's  ribs  may  be  broken  or 
other   portion   of   the   skeleton  may  be 
injured. 

Dislocations. —  Separation  of  the  epi- 
physes  of  the  long  bones  is  more  frequent 
in  the  newborn  than  the  dislocations  which 
occur  in  adults.  These  injuries  often  give 
but  little  evidence  of  their  presence,  ex- 
cept the  dislike  of  motion  on  the  part  of 
the  child,  and  sometimes  lengthening  in 
the  shaft  of  the  bone. 

The  treatment  required  is  the  same  as 
that  employed  in  fracture,  and  the  neces- 
sity for  caution  and  restraint  are  equally 
great. 

The  X-ray  hi  Fractures  and  Injuries  of 
Fetal  Bones. — By  this  method  we  are 
able  to  diagnosticate  inj  ury  to  fetal  bones 
when  otherwise  a  complete  diagnosis 
would  be  impossible.  While  the  amount 
of  calcareous  material  in  fetal  bone  is 
much  less  than  in  adults,  in  the  hands  of 
experts  'satisfactory  skiagraphs  can  be 
procured.  In  all  cases  of  suspected  in- 
jury the  diagnosis  should  be  made  clear 
by  this  method. 

Dislocations. — Congenital  dislocation  of  the  head  of  the 
femur  is  the  most  important  of  fetal  dislocations.  This  may 
be  inferred  when  motion  is  impaired,  with  shortening  on  the 
affected  side.  The  x-ray  will  confirm  the  diagnosis. 

Dislocation  does  not  often  occur  in  other  fetal  joints,  for 
fracture  or  separation  of  an  epiphysis  is  more  commonly  ob- 
served. 


Fig.  161.— Cal- 
lus in  fracture  of 
the  fetal  humerus. 


438  MANUAL   OF   OBSTETRICS 

Injuries  to  the  Nervous  System  of  the  Newborn. — The 
brain  of  the  child  may  be  subjected  to  injurious  pressure,  pro- 
ducing laceration  of  the  vessels  with  hemorrhage,  softening 
of  cerebral  tissue,  and  permanent  injury.  This  most  often 
follows  fracture  or  depression  of  the  cranial  bones,  and  may 
become  apparent  gradually  during  the  first  week  or  ten  days 
of  life. 

The  symptoms  of  the  condition  depend  upon  the  part  of 
the  brain  which  is  injured,  or  which  is  subjected  to  pressure 
through  hemorrhage. 

Injury  to  Nerve  Trunks. — The  brachial  or  axillary  plexuses 
may  be  injured  when  the  arms  are  thrown  forcibly  about  the 
head  in  complicated  labor.  In  severe  cases  the  nerve  trunks 
may  be  ruptured  or  so  severely  stretched  that  minute  hem- 
orrhage may  occur  in  the  nerve  sheaths,  thus  injuring  the 
neurilemma  by  pressure.  In  injuries  to  the  brachial  plexus, 
loss  of  motion,  disturbances  of  nutrition  in  the  muscles, 
atrophy,  and  sometimes  spastic  contraction  of  muscles,  may 
result.  These  effects  of  injury  do  not  at  once  become  ap- 
parent, and  if  slight  may  escape  observation. 

Good  results  have  been  obtained  by  exposing  the  injured 
plexus,  by  incision,  repairing  torn  nerve  trunks  with  a  very 
fine  suture,  resecting  the  injured  portions,  or  performing  an- 
astomosis in  such  a  manner  as  to  utilize  the  sound  portions 
of  the  plexus.  In  choosing  the  time  for  operation  the  sur- 
geon must  not  delay  until  permanent  injury  has  resulted. 

Injuries  to  the  Organs  of  Special  Sense. — Where  the  for- 
ceps has  been  forcibly  and  unskilfully  applied  such  injury- 
may  be  inflicted  upon  the  eye  as  to  result  in  blindness. 

In  the  experience  of  the  writer  a  case  was  brought  to  hos- 
pital where  repeated  and  unskilful  attempts  to  deliver  with 
forceps  had  been  made.  Abdominal  section  was  performed 
and  a  large  child  delivered,  which  survived.  The  forehead 
and  both  eyes  were  much  bruised,  and  for  some  time  the  ex- 
tent of  injury  could  not  be  accurately  ascertained.  Finally 
one  eye  was  evidently  not  seriously  damaged,  while  in  the 
other  the  cornea  had  been  wounded  and  the  anterior  cham- 
ber ruptured.  The  child  was  taken  to  ophthalmological 
clinics  but  it  was  found  that  the  sight  had  been  permanently 
lost. 


INJURIES   TO   THE   FETUS   IN   LABOR 


439 


The  external  ear  may  be  wounded  and  lacerated  by  unskil- 
ful efforts  to  deliver,  and  the  deeper  portions  of  the  ear  are 
occasionally  permanently  damaged.  In  some  instances 
deafness  may  become  apparent  as  the  child  grows  older, 
while  it  may  be  impossible  to  accurately  locate  the  injury. 
In  these  cases,  however,  birth  pressure  through  long  delayed 
labor,  or  through  the  use  of  forceps,  or  rapid  extraction,  will 
be  found  to  have  been  present. 


Fig.  162. — Child's  head  bruised  by  attempts  at  forceps  delivery. 
The  mother  delivered  by  section.  The  child  survived,  losing  the  sight 
of  the  injured  eye. 

Sudden  Death  in  the  Newborn. — During  the  first  three  or 
four  days  after  birth  the  newborn  child  may  be  suddenly 
taken  with  failure  of  respiration,  disturbed  heart  action,  and 
great  change  in  facial  color.  If  stimulation  be  promptly  ad- 
ministered, the  child  will  often  rally  and  may  survive;  but 
if  delay  is  practised  the  result  may  be  fatal. 

It  is  difficult  to  accurately  ascertain  the  cause  of  this 
alarming  condition.  It  is  sometimes  associated  with  enlarge- 
ment of  the  thymus  gland,  and  is  apparently  caused  by  sud- 
den turgescence  of  the  gland  and  by  pressure  on  the  trachea 
and  vessels  and  nerve  trunks  in  the  thorax.  In  some  cases 


440  MANUAL    OF    OBSTETRICS 

mucus  which  the  child  has  inspired  during  birth  seems  to 
temporarily  plug  the  air  passages. 

When  these  symptoms  develop,  artificial  respiration  should 
be  gently  but  thoroughly  practised,  and  the  child  given 
strychnia,  digitalin  and  atropin,  by  hypodermatic  injection. 
Counter-irritation  should  be  applied  over  the  chest  and  ex- 
ternal warmth.  So  soon  as  the  child  rallies,  the  intestines 
should  be  thoroughly  irrigated  with  warm  boiled  water.  In 
our  experience,  some  of  these  cases  have  recovered  under  this 
treatment  and  the  children  have  survived  and  subsequently 
developed  normally. 


CHAPTER  XXIX 
MIXED  FEEDING 

Whore  the  mother's  milk  is  insufficient  for  the  child,  it  may 
be  necessary  to  supplement  it  artificially.  This  is  better 
than  abandoning  nursing,  for  nursing  aids  in  the  involution 
of  the  mother's  generative  trad  and  is  of  great  value  to  the 
child  should  it  become  temporarily  ill. 

To  supplement  the  mother's  nursing  successfully,  the 
mother's  milk  must  be  imitated  as  closely  as  possible.  For 
this  purpose,  a  chemical  examination  of  the  breast  milk 
should  be  made  to  determine  its  percentages  of  fat,  sugar 
and  protein.  A  microscopic  examination  should  be  made  to 
show  the  relative  size  of  the  milk  globules,  and  a  bacterio- 
logical test  should  be  added. 

Cow's  milk  should  be  so  modified  as  to  imitate  as  closely 
as  possible  the  percentages  of  the  mother's  milk.  This  is 
readily  done  by  obtaining  certified  milk  with  cream  of  known 
fat  percentage,  and  using  a  formula  which  is  practically 
identical  with  that  of  the  mother's  milk.  Remembering 
that  cow's  milk  is  less  digestible  to  the  human  infant  than 
the  mother's,  the  percentage  of  fat  and  protein  should  be 
somewhat  less  than  that  of  the  mother's  milk.  If  the  cow's 
milk  be  pure,  it  should  not  be  pasteurized  nor  sterilized. 

If  the  child  finds  difficulty  in  digesting  its  artificial  food, 
this  may  be  partially  predigested  by  the  use  of  pancreatin 
and  sodium  bicarbonate. 

In  employing  mixed  feeding  it  is  often  convenient  to  pre- 
serve the  mother's  nursing  for  the  latter  part  of  the  day  and 
night,  and  to  use  artificial  food  during  the  early  part  of  the 
day,  when  it  can  be  more  conveniently  prepared.  In  many 
cases,  if  the  mother  is  relieved  from  the  burden  of  entirely 
feeding  the  child,  the  supply  of  milk  may  be  increased  and 

she  will  be  able  to  do  more  than  she  otherwise  would  have 

441 


442  MANUAL    OF   OBSTETRICS 

done.  On  the  other  hand,  if  the  child  becomes  accustomed 
to  the  bottle  and  the  mother  is  taken  ill,  or  circumstances 
arise  which  makes  it  impossible  for  her  to  nurse,  the  child 
may  readily  be  completely  weaned. 

In  cases  where  the  child  seems  unable  to  digest  cow's  milk 
and  the  mother  cannot  nurse  it  completely,  the  child  may  be 
successfully  fed  by  obtaining  the  necessary  chemical  ele- 
ments for  its  food,  in  condensed  milk,  whey  and  barley  water. 
The  fat  necessary  may  be  obtained  by  using  an  emulsion  of 
olive  oil,  given  separately  several  times  daily.  Some  children 
who  cannot  digest  cow's  milk  in  any  other  form  will  do  well 
by  this  method  of  feeding. 

A  considerable  percentage  of  fat  can  be  introduced  into 
the  child's  body  by  inunctions  of  two  parts  of  olive  oil  and 
one  of  alcohol,  given  night  and  morning.  To  secure  the  best 
results,  the  child  should  first  be  bathed  quickly,  but  thor- 
oughly, with  warm  water  and  with  a  mild  and  pure  soap. 
Immediately  after  the  bath  the  inunction  is  given  with 
gentle  but  thorough  massage.  Several  drachms  of  olive 
oil  can  thus  be  rubbed  into  the  child  at  each  massage,  and 
the  result  is  usually  highly  beneficial. 

Wet  Nursing. — Where  the  mother  cannot  nurse  the  child, 
the  wet  nurse  was  formerly  the  only  reliable  substitute.  Un- 
fortunately, the  circumstances  under  which  wet  nurses  are 
usually  obtained  are  such  as  to  render  them  unreliable  and 
unsatisfactory.  If  the  wet  nurse  is  the  mother  of  an  il- 
legitimate child,  she  may  also  be  a  person  who  has  a  specific 
disease,  or  who  is  of  doubtful  character.  If  her  own  child 
be  living,  she  should  nurse  both  her  own  and  her  foster-child, 
and  few  women  can  accomplish  so  much.  If  she  puts  away 
her  own  child,  her  mental  disturbance  may  be  such  as  to 
affect  her  milk. 

The  experiment  has  been  recently  tried  of  establishing  a 
bureau  for  wet  nurses,  where  responsible  women  are  en- 
couraged to  signify  their  willingness  to  perform  this  function. 
It  is  understood  that  the  wet  nurse  takes  her  own  child  with 
her,  if  it  be  living,  and  that  she  nurses  both  her  own  and  her 
foster-child.  This  has  worked  fairly  well  in  a  limited  number 
of  cases. 


MIXED    FEEDING  443 

The  Examination  of  a  Wet  Nurse. — Before  a  wet  nurse 
is  allowed  to  assist  a  mother,  the  wet  nurse  must  be  thor- 
oughly examined  to  determine  her  physical  condition.  The 
Wassermann  reaction  should  be  accurately  made,  and  any 
other  reliable  tests  to  determine  the  presence  or  absence  of 
syphilis  and  tuberculosis.  The  examination  of  the  genital 
tract  should  also  form  part  of  the  investigation  to  determine 
the  presence  or  absence  of  gonorrhea,  or  some  chronic  septic 
condition. 

In  the  management  of  wet  nurses,  it  is  often  difficult  to 
procure  for  them  sufficient  out-door  exercise  to  maintain  the 
general  health.  Their  nutrition  should  be  looked  after,  and 
the  wet  nurse  should  be  under  the  supervision  of  a  physician. 


CHAPTER  XXX 

THE  MEDICO-LEGAL  ASPECT  OF  OBSTETRIC 
PRACTICE 

Legal  Requirements  for  Obstetric  Practice.— To  qualify 
legally  for  the  practice  of  obstetrics  different  requirements  in 
different  states  must  be  satisfied.  All  states  recognize  prac- 
titioners of  medicine,  including  obstetrics,  and  some  have 
provision  by  which  midwives  may  practice.  Large  cities 
often  have  separate  provisions  for  the  regulation  of  the  work 
of  midwives. 

The  general  standard  of  the  profession  in  the  United 
States  calls  for  a  definite  number  of  hours  spent  in  attendance 
upon  lectures,  demonstrations  and  quizzes  on  obstetrics  in  a 
medical  curriculum.  To  this  is  added  attendance  upon  ob- 
stetric cases.  The  State  Board  of  Pennsylvania  requires 
essentially  a  five  years'  medical  course,  the  fifth  year  being 
spent  as  a  resident  in  hospital.  During  the  fourth  collegiate 
year  the  student  is  to  receive  practical  instruction  from  six 
obstetric  cases,  and  during  his  hospital  year  as  resident  he  is 
to  study  six  cases  in  addition,  making  a  minimum  total  of 
twelve. 

In  general,  the  courts  recognize  that  anyone  assuming 
the  care  of  parturient  women  must  show  graduation  from  a 
reputable  medical  school,  average  knowledge,  skill  and  ex- 
perience, and  faithful  attention  to  the  case  in  question. 
Undoubtedly  the  licensure  from  a  State  Board  would  be 
considered  important. 

It  is  also  obligatory  upon  those  attending  confinement 
cases  to  report  the  birth  of  the  child,  to  report  cases  of  still- 
birth, and  to  give  death  certificates  for  infants  still-born, 
or  dying  soon  after  birth,  and  for  mothers  dying  from  preg- 
nancy, labor,  or  the  puerperal  period.  These  returns  can- 
not legally  be  made  by  an  unqualified  person. 

444 


MEDICO-LEGAL   ASPECT   OF   OBSTETRIC    PRACTICE        445 

Confidential  Knowledge. — It  is  a  matter  generally  ac- 
cepted by  courts  that  information  gained  by  a  physician  in 
the  discharge  of  professional  duty  is  a  privileged  communica- 
tion and  that  this  need  not  be  divulged.  Obstetric  cases 
are  often  of  considerable  local  and  social  interest,  and  as 
pregnancy  may  be  illegitimate,  statements  may  be  made 
reflecting  upon  the  character  of  an  individual.  Should  a 
physician  called  to  a  patient  whom  he  found  illegitimately 
pregnant  betray  this  knowledge  to  the  injury  of  the  patient's 
reputation,  he  might  be  liable  for  damages.  A  noteworthy 
example  of  this  occurred  a  few  years  ago  in  a  foreign  country, 
where  one  of  the  leading  obstetricians  of  the  world  was  called 
to  attend  a  patient  in  miscarriage  where  there  was  doubt  as 
to  the  legitimacy  of  the  pregnancy.  Without  stating  his 
reasons,  he  advised  the  members  of  his  family  not  to  meet 
socially  the  patient  in  question.  This  caused  remark  and 
led  to  a  suit  for  libel  against  the  physician,  which  at  the  first 
hearing  was  decided  against  him. 

In  cases  of  criminal  abortion  where  a  reputable  physician 
is  called  to  the  patient  after  the  abortionist  has  done  his 
work,  the  physician  should  keep  the  patient's  confidence. 
This,  however,  does  not  excuse  him  from  cooperating  with 
the  authorities  to  discover  the  identity  of  the  abortionist  and 
to  secure  his  apprehension. 

As  obstetric  cases  often  excite  considerable  domestic  and 
local  interest  and  are  invariably  the  subject  of  gossip,  the 
obstetrician  must  be  unusually  discreet  and  reserved  in 
what  he  says  about  them.  It  is  better  to  err  upon  the  side 
of  caution  than  to  be  subjected  to  criticism,  just  or  unjust, 
for  betraying  personal  matters. 

The  Obstetrician's  Legal  Responsibilities  for  Asepsis  and 
Antisepsis  and  for  the  Occurrence  of  Septic  Infection. — 
The  practitioner  of  obstetrics  is  supposed  to  exercise  all 
reasonable  precaution  in  the  practice  of  asepsis  and  anti- 
sepsis in  the  conduct  of  labor.  He  is  responsible  for  the 
condition  of  his  hands,  for  the  use,  or  lack  of  use,  of  gloves, 
for  the  condition  of  his  instruments,  appliances,  dressings  and 
materials;  and  if  he  recommends  the  nurse  he  is  indirectly 
responsible  for  her  observance  of  antiseptic  precautions. 
Should  septic  infection  occur  in  his  practice,  he  would  be 


446  MANUAL   OF   OBSTETRICS 

liable  to  censure  and  probably  to  action  for  damages,  unless 
he  could  show  that  he  had  taken  all  reasonable  and  usual 
precautions,  and  that  extraordinary  circumstances  had 
made  the  occurrence  of  infection  possible. 

The  fact  that  the  general  practitioner  of  medicine  who  at- 
tends obstetric  patients  does  not  limit  his  practice  to  aseptic 
cases,  but  opens  abscesses,  attends  diphtheria,  scarlatina, 
and  other  infectious  diseases,  while  maintaining  his  obstetric 
practice,  makes  him  a  more  dangerous  individual  to  his 
patient  than  the  obstetric  specialist,  who  maintains  a  con- 
stant effort  to  avoid  infection.  If,  however,  the  patient 
employs  the  general  practitioner,  knowing  him  to  be  a  gen- 
eral practitioner,  and  if  under  his  care  septic  infection  de- 
velops through  diphtheria  or  scarlatina  or  some  other  case 
in  his  general  practice,  the  patient  is  taking  this  risk  in  em- 
ploying the  general  practitioner.  If  the  general  practitioner 
can  show  that  he  has  used  ordinary  and  accepted  methods, 
and  that  he  has  made  a  conscientious  effort  to  conduct  his 
obstetric  practice  properly,  he  cannot  be  held  liable  for  dam- 
age for  infection  arising,  because  of  the  nature  of  his  practice. 
The  patient  took  that  risk  in  employing  a  general  practitioner. 

Cases  in  which  suit  for  damage  is  threatened  or  some- 
tunes  brought  for  septic  infection  occurring  in  obstetric  cases 
are  those  where  the  whole  or  part  of  a  placenta  has  been  left 
in  the  uterus,  or  where  it  has  been  notably  observed  that  the 
physician  was  careless  in  sterilizing  his  hands,  gloves,  instru- 
ments, or  appliances.  The  public  are  sufficiently  familiar 
with  modern  medicine  to  recognize  these  conditions  as  un- 
usual and  resulting  from  negligence  or  ignorance. 

The  Responsibility  for  Injuries  Occurring  During  Labor. — 
Where  extensive  laceration  of  the  pelvic  floor  occurs  during 
labor  and  the  practitioner  makes  no  effort  to  repair,  he  would 
be  liable  for  damages.  The  fact  that  laceration  has  occurred 
does  not  necessarily  reflect  upon  him,  as  the  circumstances 
of  birth  may  be  such  that  laceration  was  inevitable;  nor 
would  failure  of  union  in  tissues,  which  he  closed  by  suture 
necessarily  convict  him  of  negligence  or  of  incompetence, 
for  this  accident  may  happen  in  competent  hands.  But  his 
failure  to  attempt  to  repair  lacerations  at  some  suitable  time, 
and  by  some  recognized  method,  would  be  hard  to  excuse 


MEDICO-LEGAL   ASPECT   OF   OBSTETRIC    PRACTICE        447 

or  defend,  and  cases  have  occurred  in  which  suits  for  dam- 
age were  justly  brought. 

Permission  for  Operations. — It  is  commonly  held  that 
when  a  patient  summons  a  physician  this  act  constitutes  a 
contract,  should  the  physician  render  services,  which  obli- 
gates the  patient  for  the  physician's  services,  and  places  the 
physician  under  obligation  to  render  faithful  and  competent 
service.  Obstetric  emergencies  may  arise  so  suddenly  and 
be  so  grave  in  character  that  the  performance  of  an  obstetric 
operation  may  become  necessary  at  any  time  during  parturi- 
tion or  during  the  pregnant  condition.  It  is  customary  to 
obtain  the  consent  of  patients  for  surgical  procedures,  and 
this  consent  is  usually  reinforced  by  that  of  the  nearest  rel- 
ative or  connection.  It  is  held,  however,  by  many  that 
patients  entering  a  hospital  by  this  act  confess  their  need  for 
medical  services,  and  that  any  reasonable  operation  is  justi- 
fiable if  properly  performed  by  the  staff  of  the  hospital. 

The  advance  of  obstetric  surgery  has  now  made  many 
operations  elective — as  elective  section  and  the  induction 
of  labor.  In  these  cases  there  is  ample  time  to  obtain  the 
consent  of  the  patient  and  her  husband  or  nearest  responsible 
relative  or  friend.  In  emergencies,  the  effort  should  cer- 
tainly be  made  to  obtain  consent  for  operations,  and  in  hos- 
pital practice  the  rules  usually  applying  to  hospital  cases 
may  serve.  Where  obstetricians  are  called  to  private  houses 
in  emergencies,  it  is  sometimes  difficult  to  obtain  consent 
for  major  operations.  In  ruptured  uterus,  placenta  praevia, 
placental  separation,  and  eclampsia,  no  time  can  be  lost,  and 
the  obstetrician  should  do  his  utmost  to  place  the  facts 
plainly  before  the  relatives  of  the  patient  and  to  secure  their 
consent  to  what  is  best.  Women  in  labor  are  often  so  op- 
pressed by  suffering  that  they  will  gladly  give  consent  to  any 
procedure  which  will  terminate  their  pain,  hence  the  obste- 
trician must  be  careful  to  act  from  reason  only  and  not  to  be 
swayed  by  his  sympathy  for  a  suffering  patient.  Some  ma- 
ternity hospitals  have  found  it  a  good  rule  to  have  a  patient 
and  her  nearest  relative  sign  upon  admission  permission  for 
any  operation  that  is  necessary  by  the  staff,  should  necessity 
arise.  This  will  give  the  staff  power  to  treat  obstetric  emer- 
gencies as  may  be  necessary  without  delay. 


448  MANUAL   OF    OBSTETRICS 

Should  a  patient  be  brought  to  a  maternity  hospital  with 
ruptured  uterus,  without  a  friend  or  relative,  and  the  patient 
be  unable  to  comprehend  what  is  meant  by  operation,  the 
obstetrician  would  be  justified  in  operating  to  save  the 
patient's  life,  provided  that  his  method  was  based  upon  sound 
surgical  principles  and  was  accepted  by  the  majority  of 
obstetric  authorities.  Should  the  patient  die  after  such  op- 
eration he  could  not  justly  be  blamed,  in  view  of  the  serious 
nature  of  the  complication. 

The  Relative  Importance  of  the  Lives  of  Mother  and  Child. 
—Where  the  child  is  living  and  emergencies  arise  in  obstetric 
practice,  the  obstetrician  is  usually  asked  to  save  the  mother 
if  necessary  at  the  expense  of  the  child.  So  common  is  this 
feeling  that  it  has  become  an  axiom  of  obstetric  practice. 
Where,  however,  the  obstetrician  may  offer  to  husband  and 
wife  a  comparatively  low  rate  of  mortality  for  the  mother, 
with  an  excellent  chance  of  saving  the  life  of  the  child,  the 
husband  and  wife  may  assume  the  risk  in  the  interests  of  the 
child. 

Sterilization. — Unless  it  be  necessary  to  sterilize  a  patient 
to  save  her  life,  this  should  not  be  done  without  the  per- 
mission of  husband  and  wife.  In  elective  cases  where  children 
have  already  been  born,  and  the  physical  and  economic- 
conditions  of  the  family  are  such  that  further  child-bearing 
will  be  an  unsufferable  burden,  the  obstetrician  has  the  right, 
in  delivering  a  patient  by  section,  to  render  further  impreg- 
nation impossible.  Where  conditions  are  doubtful  and  sec- 
tion is  necessary,  as  where  septic  infection  is  present  with 
other  complications,  the  obstetrician  should  have  permission 
to  do  whatever  operation  he  thinks  necessary.  If  upon  open- 
ing the  uterus  septic  conditions  are  unquestionably  present 
and  the  mother's  general  condition  is  bad,  hysterectomy 
with  extraperitoneal  treatment  of  the  stump  or  extirpation 
of  the  uterus,  will  give  the  mother  her  best  chance  for  re- 
covery. 

Therapeutic  Abortion. — Where  the  mother's  life  is 
threatened  by  the  continuation  of  pregnancy,  therapeutic 
abortion  or  operation  for  the  removal  of  the  pregnant  uterus, 
may  be  indicated.  In  deciding  on  therapeutic  abortion,  the 
obstetrician  should  have  a  consultation,  unless  he  be  a 


MEDICO-LEGAL  ASPECT   OF   OBSTETRIC    PRACTICE        449 

specialist  of  recognized  standing.  While  therapeutic  abor- 
tion rarely  comes  under  legal  notice,  a  physician  may  be  ex- 
posed to  criticism  in  his  community  by  those  who  wish  to 
injure  his  reputation,  and  hence  the  necessity  for  the  pro- 
cedure should  be  generally  accepted. 

Criminal  Abortion. — This,  as  the  name  indicates,  is  a 
crime.  It  consists  in  destroying  by  any  means  whatsoever, 
without  just  and  sufficient  cause,  the  life  of  an  impregnated 
ovum  at  any  stage  of  its  development  before  viability  is 
reached.  After  viability  such  a  procedure  would  be  in- 
fanticide. 

The  legal  penalty  for  criminal  abortion  varies,  but  com- 
prises imprisonment  and  fine  in  varying  terms  and  amounts 
in  all  states.  The  aiders  and  abettors  in  criminal  abortion 
are  also  liable  to  punishment. 

Many  makers  and  sellers  of  so-called  abortifacient  remedies 
are  not  only  guilty  of  attempting  to  produce  criminal  abor- 
tion but  are  guilty  of  fraud  upon  their  purchasers.  Many 
of  these  preparations  are  inert  and  fail  to  produce  the  effect 
for  which  they  are  purchased. 

A  reputable  physician  cannot  be  an  abortionist  and  retain 
his  self-respect  or  the  respect  and  confidence  of  the  profession. 
No  matter  how  skilfully  or  secretly  done  criminal  abortion 
must  always  be  a  crime,  and  he  who  does  it  must  be  a  crim- 
inal. 

As  the  abortionist  rarely  sees  his  patient  after  committing 
the  crime,  they  frequently  come  into  the  hands  of  reputable 
physicians.  Such  abortion  is  not  complete,  and  many  of 
these  cases  are  infected  by  the  abortionist.  Reputable 
practitioners  are  called  upon  to  treat  incomplete  abortion  and 
septic  infection.  The  practitioner  must  keep  the  confidence 
of  his  patient  and  do  what  he  can  to  discover  and  apprehend 
the  perpetrator  of  the  crime. 

It  is  well  in  these  cases  to  avoid  interference  with  the 
uterus  until  the  practitioner  has  gained  as  much  knowledge  as 
possible  concerning  the  case,  and  has  had  an  opportunity  to 
inform  the  authorities  that  he  has  a  suspicious  case  in  his 
care.  He  need  not  betray  the  name  of  his  patient,  but  he  can 
start  inquiry  which  will  find  the  criminal,  and  which  places 

him  upon  record  as  being  an  honorable  man.     After  he  has 
29 


450  MANUAL    OF   OBSTETRICS 

notified  authorities,  he  may  undertake  whatever  treatment 
will  be  necessary,  including  operation,  realizing  that  should 
death  follow,  he  cannot  be  accused  of  having  by  his  operation 
been  the  original  cause  of  the  death.  Should  the  patient  be 
in  a  critical  condition,  or  grow  rapidly  worse,  he  should  notify 
the  authorities  at  once  to  give  them  an  opportunity  to  ob- 
tain from  the  patient  an  antemortem  statement.  Should 
death  occur,  he  should  decline  to  give  a  certificate  until  the 
coroner  has  had  an  opportunity  to  investigate.  It  is  well  to 
caution  nurses  who  are  in  attendance  upon  cases  that  have 
had  criminal  abortion  that  they  may  be  called  upon  to  give 
testimony  as  to  the  patient's  condition,  and  that  they  must 
not  betray  the  patient's  confidence  while  acting  as  a  nurse, 
by  talking  about  her  to  other  persons. 

The  physician  should  exercise  special  caution  in  dealing 
with  unknown  women  in  all  the  aspects  of  medical  and 
obstetric  practice,  and  especially  if  he  is  called  to  a  wroman 
in  the  child-bearing  age,  finding  her  with  evidences  of  pelvic 
septic  infection  and  possible  pregnancy  or  abortion,  he  should 
exercise  great  caution  in  his  management  of  the  case.  Per- 
sons evilly  disposed  may  sometimes  accuse  a  physician  un- 
justly, taking  advantage  of  such  a  case  to  gradually  injure 
his  reputation. 

Infanticide. — The  fetus  in  the  uterus  is  practically  a  part 
of  the  mother's  body  and  has  no  independent  existence. 
Once  outside  the  mother's  body  it  becomes  a  separate  in- 
dividual and  if  it  makes  one  respiratory  effort  observed  by 
credible  witnesses,  it  has  legally  lived. 

The  destruction  of  the  life  of  the  fetus  in  the  body  of  the 
mother  is  not  infanticide,  but  would  be  criminal  abortion, 
illegal  operation,  or  misdemeanor.  Infanticide  is  usually  per- 
formed by  the  mother  illegitimately  pregnant,  or  by  some 
friend  who  tries  to  hide  her  shame  by  destroying  the  child. 
Strangulation  by  pressure  upon  the  neck,  or  suffocation  by 
covering  with  a  pillow  or  blanket,  or  over-laying,  by  which 
the  pressure  of  the  mother's  body  prevents  the  child  from 
breathing,  are  the  methods  usually  employed.  It  is  often 
very  difficult  to  find  positive  proof  of  infanticide.  A  woman 
illegitimately  pregnant,  delivered  alone,  may  summon  no 
assistance  until  the  child  has  ceased  to  breathe.  In  the  ab- 


MEDICO-LEGAL   ASPECT   OF   OBSTETRIC    PRACTICE        451 

sence  of  pressure  marks  upon  the  throat,  or  signs  of  direct 
interference,  infanticide  is  difficult  to  prove. 

It  was  formerly  thought  that  postmortem  examination 
should  demonstrate  that  air  had  entered  the  infant's  lungs,  or 
that  it  never  had  breathed.  This  is  not  an  invariable  test, 
for  the  child's  lungs  are  not  expanded  fully  for  several  days 
after  birth,  and  methods  of  artificial  respiration  may  force 
air  into  the  lungs  of  the  child  which  never  breathed  spon- 
taneously. If,  however,  it  could  be  shown  that  the  mother 
had  no  medical  attention  at  birth,  that  she  was  found  with 
the  child  dead,  and  autopsy  showed  air  to  any  appreciable 
extent  in  the  child's  lungs,  the  inference  would  be  a  fair  one 
that  the  child  had  inspired;  but  if  medical  attendance  had 
been  at  hand,  and  the  physician  had  made  efforts  at  artificial 
respiration,  air  might  still  be  in  the  lungs,  and  the  child  never 
have  spontaneously  breathed. 

Infanticide  may  be  perpetrated  or  attempted -by  throwing 
newborn  infants  into  cesspools,  or  out  of  railway  trains,  or 
into  deserted  places  behind  fences,  so  that  death  may  be 
spontaneous.  The  viability  of  the  newborn  infant,  under 
these  circumstances,  is  sometimes  surprising.  In  the  ob- 
servation of  the  writer,  a  newborn  infant  was  thrown  into  a 
cesspool  on  an  exceedingly  cold  winter's  night.  The  con- 
tents of  the  pool  were  so  frozen  that  the  child  did  not  sink, 
and  its  cry  was  heard  by  a  passing  policeman,  who  rescued 
it  alive. 

While  it  might  not  be  proved  from  marks  of  physical  in- 
jury that  a  child  found  in  a  deserted  place  had  been  strangled, 
if  the  child  could  be  traced  to  the  mother  or  her  attendant, 
the  act  of  desertion  and  the  abandoning  of  the  child  with- 
out care,  would  constitute  infanticide. 

Over-laying. — Where  the  mother  is  exhausted  and  lies 
in  a  heavy  sleep  with  her  infant  in  the  bed  with  her,  or  where 
she  is  drunk,  she  may  turn  upon  the  child  and  suffocate  it 
by  her  weight.  This  is  called  over-laying  and  is  not  uncom- 
mon among  the  exhausted  and  vicious  poor  of  large  cities. 

Sudden  Death  in  Infants. — An  infant  under  good  care 
is  sometimes  found  dead,  or  dies  suddenly  without  known 
cause.  In  these  cases  some  trivial  circumstance  may  be 


452  MANUAL    OF    OBSTETRICS 

alleged  as  the  cause  of  death — as  the  placing  of  the  child  upon 
a  pillow.     Unjust  blame  and  suspicion  may  be  aroused. 

These  cases  should  invariably  come  to  autopsy,  for  it 
must  be  remembered  that  there  are  several  conditions  in  the 
newborn  infant  which  make  sudden  death  possible  without 
interference.  One  is  the  sudden  enlargement  of  the  thymus 
gland,  causing  pressure  on  the  thoracic  viscera.  Another  is 
the  failure  of  the  Eustachian  valve  in  the  heart  to  close;  and 
still  another  is  the  occurrence  of  pulmonary  apoplexy  or 
cerebral  apoplexy  in  children  that  have  been  born  in  long 
and  difficult  labor. 


fyoSfifin 

-''J>:iJ 

£/<//,  • 


INDEX 


ABDERHALDEX'S  serum  test,  89 
Abdomen,    contour    of,    in    preg- 
nancy, 47 
Abdominal  binder,  317 

cesarean  section,  381 

inflammations,   effect  on  preg- 
nancy, 133 

palpation,  outlining  fetus  by,  75 

pregnancy,  238 

Abnormalities  in  size  of  fetus,  414 
Abortion,  140 

cause  of,  140 

criminal,  147,  449 

diagnosis,  142 

incomplete,  143 

inevitable,  143 

pathology  of,  143 

prevention  of,  144 

therapeutic,  147 
legal  aspect  of,  448 

threatened,  143 

treatment  of,  145 

tubal,  142 
Abrasions  of  hands,  treatment  of, 

314 

Abscess,  breast,  301 
Accidents  caused  by  forceps,  338 

effect  of,  on  pregnancy,  132 
Accouchement  force,  376 
Acute  yellow  atrophy  of  liver  in 

pregnancy,  130 
Adnexa,   fetal,    abnormalities   of, 

426 
Alcohol,    effect    on    mother    and 

child,  132 


Alcoholism,  effect  on  fetus,  424 

Allantois,  54 

Amnion,  54 

Amniotic  liquid,  discharge  of,  169 

Anatomy  of  birth  canal,  42 

of  normal  pelvis,  19 
Anesthesia,  obstetric,  179 
Anesthetics  in  labor,  175 
Anteroposterior    diameter,    meas- 
urement of,  82 

of  outlet,  measurement  of,  85 
Antisepsis,  obstetric,  280,  307 

uterine,  308 

Antitoxin  in  puerperal  septic  in- 
fection, 283 

Anus,  imperforate,  of  fetus,  426 
Appendages,  fetal,  62 
Appendicitis    complicating    preg- 
nancy, 124 

effect  on  pregnant  women,  133 
Appetite  in  pregnancy,  94 
Appliances,  preparation  of,  314 
Arsenical     poisoning,     effect     on 

mother  and  child,  131 
Arteriosclerosis     and     pregnancy, 

130 
Asepsis  in  care  of  hands,  312 

obstetric,  280,  307 

of    wound    accompanying    de- 
livery, 310 
Aseptic  preparation  of  patient  for 

operation,  321 
Asphyxia,  fetal,  429 
Atresia   complicating   pregnancy, 

139 


453 


454 


INDEX 


Auscultation  in  diagnosis  of  preg- 
nancy, 79 
prognosis  by,  80 
Autoinfection,  279 
Autositic  monsters,  416 
Axis  of  birth  canal  in  pregnancy, 

45 

pelvic,  23 
Axis-traction  forceps,  326 


BAGS,  dilating,  for  inducing  labor, 
376 

in  uterine  inertia,  214 
in  placenta  prsevia,  245 
Bandages,  breast,  300 
Bandl's  ring,  409 
Baptism  in  craniotomy,  362 
Barnes'  bag,  376 
Basiotribe,  361 
Binder,  abdominal,  317 

breast,  300 

Birth  canal,  anatomy  of,  42 
axis  of,  in  pregnancy,  45 
care  of,  307 
lacerations  of,  antiseptic  care 

of,  310 

Birth-pressure,  428 
Birth-marks,  425 
Blighted  ovum,  141 
Blood  in  pregnancy,  93 
Blood-vessels,  development  of,  55 
Bones  in  pregnancy,  97 
Braxton-Hicks'  method  of  version, 

345 

in  placenta  prsevia,  248 
Breast  abscess,  301 

binder,  300 

Breasts  after  death  of  infant,  302 
aseptic  care  of,  309 
care  during  lactation,  299 
in  pregnancy,  71 
in  puerperal  period,  297 
painful,  301 


Breech  presentation,  203 

forceps  in,  336 

mechanism  of,  160 
Broad  ligament  pregnancy,  44,  235 
Brow  presentation,  193 


CANCER  of    uterus    complicating 

'    pregnancy,  136 

Catheter,    antiseptic    precautions 

with,  311 

Cephalotripsy,  359 
Cerebrospinal   meningitis  compli- 
cating pregnancy,  121 
Cervix,  dilatation  of,  in  labor,  169 
in  uterine  inertia,  214 

examination  of,  73 

in  pregnancy,  44 

lacerations  of,  repair  of,  368 
Cesarean  section,  381 
abdominal,  380 
extraperitoneal,  386 
by  inguinal  incision,  388 
vaginal,  388 
Champetier  de    Ribes    bag,   214, 

376 
Child,  effect  of  forceps  delivery  on, 

341 

Chin,  posterior  rotation  of,  194 
Cholecystitis    complicating    preg- 
nancy, 122 
Chorion,  54 
Circulation,  fetal,  59 

of  embryo,  52 

of  placenta,  64 
Clavicle,  fracture  of,  during  labor, 

435 

Cleidotomy,  362 
Clothing  in  pregnancy,  99 
Coccyx,  anatomy  of,  21 

injuries  to,  in  labor,  372 
Colitis,  effect  on  pregnant  women, 

133 
Colostrum,  297 


INDEX 


455 


Combined  version,  345 
Complications  of  pregnancy,   ab- 
normal   pelvic    conditions, 
133 

abortion,  140 

accidents,  132 

acute  yellow  atrophy,  130 

appendicitis,  124 

art  rriosclerosis,  130 

atresia,  139 

bacillus  coli  infection,  122 

cerebro-spinal  meningitis,  121 

cholecystitis.  122 

diphtheria,  122 

fetal  syphilis,  127 
toxemia,  116 

fibroids,  135 

gonorrhea,  125 

heart  disease,  120 

hernia,  139 

infectious  diseases,  119 

influenza,  122 

malaria,  128 

malpositions  of  pelvic  viscera, 
137 

ovarian  tumors,  134 

pelvic  tumors,  135 

pneumonia,  120 

poisons,  131 

pyelitis,  123 

retroversion  of  uterus,  137 

rheumatism,  128 

syphilis,  125 

toxemia,  103 

tuberculosis,  126 

typhoid  fever,  119 

vaccination,  121 
Conduct  of  labor,  173 

first  stage,  173 

second  stage,  184 

third  stage,  182 
Confinement,  time  of,  computing, 

101 
Conjoined  twins,  417 


Conjugate,  external,  measurement 
of,  82 

internal,  measurement  of,  85 
Constipation  in  pregnancy,  94 

treatment  of,  99 

Contraction  of  uterus  in  labor,  168 
Cord,  prolapse  of,  226 

umbilical,  62 
Corneal  pregnancy,  234 
Counter-irritation    of    cervix    in 

toxemia,  110 
Cranioclasis,  359 
Craniotomy,  358 

child  in,  362 

dangers  to  mother,  362 

of  after-coming  head,  362 

upon  living  child,  364 
Cranium,  fracture  of,  during  labor, 

433 
Criminal  abortion,  147,  449 


DEATH  in  labor,  230 
of  fetus,  422 

diagnosis  of,  91 
of  newborn,  439 
Decapitation,  363 
Delivery  forceps,  323 
indications  for,  324 
operation  of,  327 
forcible,  376 

of  fetal  bones  in  craniotomy,  364 
Descent  of  head,  154 
Diagnosis,    differential,    of    preg- 
nancy, 88 
of  pregnancy,  69 
auscultation,  79 
by  serum  test,  89 
history,  69 
later,  74 
palpation,  73 
physical  examination,  71 
Diameters  of  fetal  head,  85 
of  pelvic  brim,  25 


456 


INDEX 


Diameters  of  pelvis,  23 
measurement  of,  81 

Diet  in  pregnancy,  100 

influence  on  fetal  development, 
427 

Differential     diagnosis     of     preg- 
nancy, 88 

Digestive  organs  in  pregnancy,  94 

Dilatation  of  cervix  in  labor,  169 
in  uterine  inertia,  214 

Diphtheria      complicating     preg- 
nancy, 122 

Dislocations,   fetal,   during  labor, 
437 

Disproportion    causing   prolonged 
labor,  217 

Double  uterus  complicating  preg- 
nancy, 137 

Dressings,  317 

Drugs,  induction  of  labor  by,  378 

Duration  of  pregnancy,  101 


EARLY  pregnancy,  diagnosis  of,  69 

hygiene  of,  98 

Eclampsia.    See  Toxemia  of  Preg- 
nancy 

without  convulsions,  111 
Eclamptic  seizures,  111 
Ectoderm,  50 
Ectopic  pregnancy,  232 
Embryo,  circulation  of,  52 

death  of,  diagnosis  of,  91 

growth  and  development  of,  50 
Embryotomy,  358 
Endoderm,  50 
Engagement,  67,  152 

determination  of,  77 
Episiotomy    wounds,    closure    of, 

370 

Examination,  pelvic,  in  pregnancy, 
72 

physical,  in  pregnancy,  71 
Excretion  during  labor,  171 


External  conjugate,  measurement 
of,  82 

pelvimetry,  81 

version,  343 
Extraperitoneal  Cesarean  section, 

386 

Extension  of  placenta  in  labor,  169 
Eyes,  care  of,  306 

infection  of,  care  of,  306 


FACE  presentation,  157 

forceps  in,  336 

Fallopian  tubes  in  pregnancy,  42 
False  pelvis,  21 
Feeding,  mixed,  441 
Fetal  appendages,  62 

asphyxia,  429 

circulation,  59 

changes  in  at  birth,  61 

death,  422 

development  treatment  by  diet 
and  hygiene,  427 

head,  measurement  of,  85 

ichthyosis,  425 

infection,  422 

movements  in  diagnosis,  79 

skeleton,  disease  of,  425 

syphilis,  127,  422 

tuberculosis,  424 

tumors    complicating    delivery, 

420 
Fetus,  57 

abnormalities  in  size  of,  414 

death  of,  diagnosis  of,  91 

full-term,  58 

impaction  of,  220 

in  acute  infectious  diseases,  126 

injuries  to,  in  labor,  428 

pathology  of,  414 

physiology  of  labor  pertaining 
to,  171 

position     of,     in     relation     to 
mother,  66 


INDEX 


457 


Fetus,  septic  infection  of,  287 

size  and  weight  of,  57 

transverse  position  of,  197 
Fibroids,  effect  on  pregnancy,  135 
First,  stage  of  labor,  conduct  of,  173 
Flat  pelvis,  31 
Flexion,  152 
Forceps,  323 

accidents  caused  by,  338 

application  of,  327 

axis-traction,  326 

delivery,     effect  on  child,   341 
operation  of,  327 
shock  and  hemorrhage,  339 

description  of,  325 

improper    application    of,    336 

in  abnormal  rotation  of  occiput, 
333 

in  breech  presentation,  336 

in  face  presentation,  336 

in  posterior  rotation  of  occiput, 
335 

indications  for  use,  324 

lacerations  from,  340 

mortality  from,  340 

rotation  by,  333 

Simpson's,  325 

Tarnier,  327 
Forcible  delivery,  376 
Fracture  of  clavicle  during  labor, 
435 

of  cranium  during  labor,  433 

of  humerus,  during  labor,  436 
Full-term  fetus,  58 
Furniture  of  patient's  room,  316 

GLOVES,  use  of,  313 
Gonorrhea     complicating     preg- 
nancy, 125 
fetal,  425 

HANDS,  care  of,  312 
in  septic  cases,  314 


Hands,   preparation   of,   for  con- 
duct of  labor,  312 

wounds  and  abrasions  of,  314 
Head,  delivery  of,  178 

descent  of,  154 

holding  bark,  in  labor,  177 

of  fetus,  measurement  of,  85 

ml  at  ion  of,  154 

transverse  position  of,  195 
Heart,  development  of,  54 

disease  complicating  pregnancy, 
128 

in  pregnancy,  93 

sounds  in  pregnancy,  71 
Hemorrhage    complicating    preg- 
nancy, 256 

death  from,  271 

from  lacerations,  260 
.   in  forceps  delivery,  339 

post-partum,  263 

secondary,  269 

uncontrollable,  270 
Hemorrhoid      during      puerperal 

period,  295 
Hermaphrodite,  416 
Hernia    complicating    pregnancy, 

139 

History  of  pregnancy,  69 
Holding  back  the  head,  177 
Humerus,     fracture     of,     during 

labor,  436 
Hydrocephalus,  419 
Hygiene  of  pregnancy,  98 
Hysterical  nausea  and  vomiting, 

104 

ICHTHYOSIS,  fetal,  425 

Ilium,  20 

Impaction  of  fetus,  220 

of  shoulders,  211 

of  twins,  202 

Imperforate  anus  in  fetus,  426 
Impregnation,    abnormal,    physi- 
ology of,  40 


458 


INDEX 


Impregnation,  physiology  of,  39 
Inclination,  pelvic.  26 
Incomplete  abortion,  143 
Induction  of  labor,  373 
by  bags,  376 
by  drugs,  378 

by  rupture  of  membranes,  379 
by  suggestion,  379 
Inertia,  uterine,  211 
Inevitable  abortion,  143 
Infant,  care  of,  during  puerperal 

period,  303 

effect  of  forceps  delivery  on,  341 
protection  from  infection,  304 
supplies  for,  318 
Infanticide,  450 
Infantile  pelvis,  29 
Infants'  eyes,  care  of,  306 
Infection  complicating  labor,  228 « 
in  use  of  catheter,  311 
intestinal,  in  infants,  305 
of  birth  canal,  prevention  of,  307 
of  eyes,  306 
of  fetus,  422 

protection  of  infant  from,  304 
resistance  of  the  organism  to, 

277 
septic,  272 

in  newborn,  289 
puerperal,  275 
umbilical  region,  305 
Infectious    diseases    complicating 

pregnancy,  119 
fetus  in,  126 
Influenza  complicating  pregnancy, 

122 

Injuries  caused  by  forceps,  338 
during  labor,  responsibility  for, 

446 

in  podalic  version,  355 
to  nervous  system  of  newborn, 

438 

Inspiration    pneumonia    of    new- 
born, 288 


Instruments,  preparation  of,  314 
Internal  conjugate,  measurement 
of,  85 

pelvimetry,  82 

version,  347 
Interruption     of     pregnancy     in 

toxemia,  110 

Intestinal  infection  in  infants,  305 
Involution  of  genital  tract,  294 

of  uterus,  291 
Ischium,  21 


JOINTS,  pelvic,  26 
Justo-major  pelvis,  31 
Justo-minor  pelvis,  29 


KNEE-CHEST  position  in  prolapse 

of  cord,  227 

in  retrodisplacement,  138 
Kidney  infection  in  pregnancy,  123 
Kyphotic  pelvis,  35 


LABOR,  150 

breech  presentation,  160 
complications    of,    hemorrhage, 
256 

septic  infection,  272 
conduct  of,  173 

first  stage,  173 

second  stage,  174 

third  stage,  182 
excretion  during,  171 
face  presentation,  157 
induction  of,  373 
infection  in,  228 
injuries  to  fetus  in,  428 
mechanism  of,  151 
nervous,  system  during,  171 
pathology  of,  186 
physiology  of,  168 
prolonged,  211 


INDEX 


459 


Labor,  stages  of,  151 

sudden  death  in,  230 

vertex  presentation,  151 
Lacerated  surfaces,  aseptic  care  of, 

370 

Lacerations,  asepsis  and  antisepsis 
of,  310 

diagnosis  of,  366 

hemorrhage  from,  260 

of  cervix,  repair  of,  368 

of  pelvic  floor,  repair  of,  368 

perineal,  repair  of,  368 

prevention  of,  175,  183,  365 

treatment  of,  367 
Lactation,  297 

care  of  breasts,  299 

complications  of,  300 
Langhans'  layer,  55 
Laxatives  in  puerperal  period,  295 
Lead  poisoning,  effect  on  mother 

and  child,  131 
Legal  requirements  for  obstetric 

practice,  444 
Linen,  sterile,  315 
Lochial  discharge,  292 

examination  of  for  diagnosis, 

293 
Lungs  in  pregnancy,  93 


MALARIA  and  pregnancy,  128 

Malformations,  genital,  and  preg- 
nancy, 136 

Malpositions     of    pelvic    viscera 
complicating  pregnancy,  137 

Measurement  of  comparative  size 

of  pelvis  and  child,  85 
of  fetal  head,  85 
of  pelvis,  81 

Mechanism  of    labor,   abnormal- 
ities in,  186 

Medico-legal  aspects  of  obstetric 
practice,  444 

Membranes,  rupture  of,  169,  172 


Meningitis      complicating     preg- 
nancy, 121 

Mercurio's  position,  405 

Mesoderm,  51    . 

Milk,  deficient  secretion  of,  300 
excessive  secretion  of,  301 
secretion    in    puerperal    period, 
297 

Mixed  feeding,  441 

Momburg's  belt,  268 

Monstrosities,  415 

Mouth,  infection  of,  304 

Movements,  fetal,  in  diagnosis,  79 

Multiple  pregnancy,  252 
examination  for,  78 


NAEGELE  pelvis,  31 
Nausea,  hysterical,  104 
Nephritis  and  pregnancy,  130 
Nervous  system  during  labor,  171 
in  pregnancy,  97 
in  puerperal  septic  infection, 

284 

of  new  born,  injuries  to,  438 
Neuralgia  in  pregnancy,  97 
Newborn,  septic  infection  of,  289 

sudden  death  in,  439 
Nipples,  care  of,  300 

in  pregnancy,  71 
Nourishment  in  puerperal  period, 

295 

Nurse,    directions   from   obstetri- 
cian to,  319 
operative,  320 
wet,  442 

Nursing    in   post-partum   hemor- 
rhage, 270 
in  puerperal  septic  infection,  284 


OBLIQUE  diameter,  measurement 

of,  82 
Obstetric  anesthesia,  179 


460 


INDEX 


Obstetric  asepsis,  307 
and  antisepsis,  280 

list,  318 

operations,  320 

definition  of,  17 
Occiput,  posterior  rotation  of,  186 

forceps  in,  334 
Occupational  poisoning,  effect  of, 

131 

Oligohydramnion,  422 
Omphalositic  monsters,  416 
Operations,  320 

in  private  houses,  321 

permission  for,  legal  aspects  of, 

447 

Osteomalacic  pelvis,  34 
Outlet  of  pelvis,  25 
Ovarian  pregnancy,  232 
Ovaries,  prolapse  of,  complicating 

pregnancy,  139 
Ovary  in  pregnancy,  42 
Over-laying,  451 
Ovum,  50 

blighted,  141 


PACKING  in  post-partum  hemor- 
rhage, 266 

Palpating  presenting  part,  76 

Palpation,    abdominal,    for    out- 
lining fetus,  75 

Parental  syphilis  and  the  fetus, 
130 

Parietal    bone,    presentation    of, 
191 

Pathology  of  labor,  186 

Patient's  room  and  its  furniture, 
316 

Pelvic  axis,  23 
brim,  diameters  of,  25 
cavity,  anatomy  of,  22 
diameters,  measurement  of,  81 
examination  in  diagnosing  preg- 
nancy, 72 


Pelvic  floor,  lacerations  of,  repair 

of,  368 

protection  of,  in  labor,  175 
support  of,  365 

inclination,  26 

joints,  26 

outlet,  22 

planes,  23 

tumors,  effect  on  pregnancy,  135 
Pelvimetry,  external,  81 

internal,  82 

Pelvis,  abnormal,  anatomy  of,  29 
pregnancy  of,  37 

anatomy  of,  19 

changes  in,  in  pregnancy,  45 

deformity  from  disease,  37 

diameters  of,  23 

effect  of  injury  in,  36 

false,  21 

flat  rhachitic,  31 

forces  developing,  27 

generally  contracted,  29 

infantile,  29 

injuries  to,  in  labor,  372 

justo-major,  31 

justo-minor,  29 

kyphotic,  35 

measurement  of,  81 

Naegele,  31 

of  child,  27 

osteomalacic,  34 

rhachitic,  32 

Robert,  31 

simple  flat,  31 

symmetrically  large,  31 

true,  22 

Perineal  lacerations,  repair  of,  368 
Perineum,  lacerations  of,  preven- 
tion of,  175 

support  of,  365 

Peritoneal   fistule,    Cesarean   sec- 
tion by,  387 
Permission   for   operations,    legal 

aspect  of,  447 


INDEX 


461 


Pernicious  nausea,  103 

vomiting,  103 
Physical  examination  in  diagnosis 

of  pregnancy,  71 
Physiology  of  impregnation,  39 
of  labor,  118 
of  pregnancy,  93 
Placenta,  63 

accidental  separation  of,  256 
circulation  of,  64 
delivery  of,  182 
extrusion  of,  in  labor,  169 
position    of,    examination    for, 

87 
praevia,  240 

in  early  months,  251 
Placental  sound,  79 
Planes,  pelvic,  23 
Pneumonia     complicating     preg- 
nancy, 120 

inspiration,  of  new-born,  288 
Podalic  version,  347 
Poisoning  during  pregnancy,  131 
Poisons,  effect  on  fetus,  425 
mother  and  child,  131 
Polyhydramnios,  420 
Pomeroy  bag  in  uterine  inertia, 

214 

Position,  Mercurio's,  405 
of  fetus,  66 

examination  for,  75 
of    placenta,    examination    for, 

87 

Walcher's,  405 

Posterior  occiput,  forceps  to,  334 
rotation  of  chin,  194 
of  occiput,  186 
of  trunk,  203 
Post-partum  hemorrhage,  263 

nursing  in,  270 

Posture  of  pregnant  women,  46 
Pregnancy,  65 
abdominal,  238 
broad  ligament,  235 


Pregnancy,  complications  of,  sep- 
tic  infection,  274 
diagnosis  of,  69 

later,  74 
ectopic,  232 
history  of,  69 
hygiene  of,  98 
multiple,  252 

examination  for,  78 
ovarian,  232 
physiology  of,  92 
posture  and  attitude  in,  46 
toxemia  of,  103 
tubal,  233,  234 
twin,  252 

Preparation  of  patient  for  opera- 
tion, 321 
Presentation,  65 
breech,  203 

mechanism  of,  100 
brow,  193 
diagnosis  of,  75 
face,  157 

of  parietal  bone,  191 
shoulder,  197 

recognition  of,  78 
vertix,  151 
Presenting  part,  65 

palpating,  76 

Prevention  of  laceration,  183 
Private  houses,  operations  in,  321 
Prognosis  by  auscultation,  80 
Prolapse  of  cord,  226 
of   ovaries    complicating   preg- 
nancy, 139 
Prolonged  labor,  211 

from  disproportion,  217 
from  uterine  inertia,  217 
Pubes,  21 
Pubiotomy,  403 
Puerperal  period,  291 

cure  of  infant  during,  303 
lactation  in,  297 
urine  during,  296 


462 


INDEX 


Puerperal  septic  infection,  275 
Pulse  in  pregnancy,  93 
Pyelitis  of  pregnancy,  123 


QUADRUPLETS,  255 


RECTAL   tube,  prevention    of  in- 
fection from,  311 

Retroversion  of  uterus  complicat- 
ing pregnancy,  137 

Rhachitic  pelvis,  32 

Robert  pelvis,  31 

Room  for  confinement,  316 

Rotation  by  forceps,  333 
of  chin,  posterior,  194 
of  head,  154 
of  occiput,  posterior,  186 

forceps  in,  334 
of  trunk,  posterior,  203 

Rupture  of  membranes,  169,  172 

induction  of  labor  by,  379 
of  uterus,  221,  408 
of    vessels    complicating    preg- 
nancy, 260 


SACROILIAC  strain,  372 
Sacrum,  20 

Salpingitis  and  pregnancy,  134 
Second  stage  of  labor,  conduct  of, 

174* 

Secondary  hemorrhage,  269 
Separation  of  placenta,  256 
Septic  cases,  hands  in,  314 
infection,  272 

of  fetus,  287 

of  newborn,  289 

puerperal,  275 

Serum  test  for  pregnancy,  89 
Shock  in  forceps  delivery,  339 
Shoulder  presentation,  197 

recognition  of,  78 


Shoulder,  delivery  of,  179 

impaction  of,  211 
Simpson's  forceps,  325 
Skeleton,  fetal,  disease  of,  425 

in  pregnancy,  97 

Skin,   abnormalities  of,   in  fetus, 
425 

antiseptic  care  of,  309 

in  pregnancy,  96 

preparation    of,    for   operation, 

309 

Sound,  placental,  79 
Spondylolisthesis,  36 
Stages  of  labor,  151 
Sterilization,  legal  aspect  of,  448 
Sterilizing  instruments,  315 
Sudden  death  in  labor,  230 
Suggestion,  induction  of  labor  by, 

379 

Symphysiotomy,  400 
Syncytium,  55 

Syphilis  complicating  pregnancy, 
125 

fetal,  127,  422 

parental,  and  the  fetus,  130 


TAMPONING       for       post-partum 

hemorrhage,  266 
Tarnier  forceps,  327 
Teeth  in  pregnancy,  96 
Temperature  in  pregnancy,  96 
Therapeutic  abortion,  147 

legal  aspect  of,  448 
Third  stage  of  labor,  conduct  of, 

182 

Threatened  abortion,  143 
Tobacco     poisoning,     effect     on 

mother  and  child,  131 
Toxemia,  fetal,  116 

of  later  pregnancy,  111 

of  pregnancy,  103 
Transverse     diameter     measure- 
ment of,  82 


INDEX 


463 


Transverse  position  of  fetus,  197 
of  head,  195 
recognition  of,  78 

Triplets,  255 

True  pelvis,  22 

Trunk,  posterior  rotation  of,  203 

Tubal  abortion,  142 
pregnancy,  233 

Tuberculosis    complicating    preg- 
nancy, 126 
fetal,  424 

Tumors,    fetal,    complicating   de- 
livery, 430 

Twin  pregnancy,  252 
conjoined,  417 
impaction  of,  202 

Typhoid  fever  complicating  preg- 
nancy, 119 


UMBILICAL  cord,  62 
care  of  stump,  303 
long,  426 

rupture  during  labor,  427 
short,  427 

strangulation  by,  426 
region,  infection  of,  305 
Uncontrollable  hemorrhage,  270 
Urethra,  imperf orate,  in  fetus,  426 
Urine  during  puerperal  period,  296 

in  pregnancy,  95 
Uterine  inertia,  211 
Uterus,  cancer  of,  complicating 

pregnancy,  136 
antiseptic  care  of,  308 
contractions  of,  in  labor,  168 
in  pregnancy,  42 


Uterus,  involution  of,  291 

retroversion     of,     complicating 

pregnancy,  137 
rupture  of,  221,  408 


VACCINATION  and  pregnancy,  121 
Vagina  in  pregnancy,  44 
Vaginal  Cesarean  section,  388 

examination  in  pregnancy,  73 
Varicose  veins  in  vagina,  200 
Version,  343 

combined,  345 

external,  343 

internal,  347 

podalic,  347 

Vertex  presentation,  151 
Villi  of  chorion,  55 
Vomiting,  hysterical,  104 

pernicious,  103 
Voorhees  bag,  376 

in  uterine  inertia,  214 
Vulva,  examination  of,  73 


WALCHER'S  position,  405 
Weight  in  pregnancy,  96 
Wet  nursing,  442 
Wolffian  body,  53 
Womb.     See  Uterus 


X-ray,  diagnosis  of  pregnancy  by, 

92 

in  diagnosing  injuries  to  fetal 
bones,  437 


SAUNDERS'  BOOKS 


Practice,  Pharmacy, 
Materia  Medica,  Thera- 
peutics, Pharmacology, 
and  the  Allied  Sciences 

W.   B.  SAUNDERS  COMPANY 

West  Washington  Square  Philadelphia 

9,  Henrietta  Street  Covent  Garden,  London 

Our  Handsome  Complete  Catalogue  will  be  Sent  You  on  Request 

B&stedo's  Materia  Medica,  Pharmacology, 
Therapeutics,  and     Prescription     iVriting 

By  W.  A.  BASTEDO,  M.  D.,  Associate  in  Pharmacology  and 
Therapeutics  at  Columbia  University.  Octavo  of  602  pages, 
illustrated.  Cloth,  $3.50  net. 

THREE  PRINTINGS  IN  SIX  MONTHS 

Dr.  Bastedo's  new  work  has  the  distinct  advantage  of  presenting  the 
subjects  from  both  the  laboratory  and  the  clinical  sides.  Dr.  Bastedo  for 
many  years  devoted  his  entire  time  to  laboratory  work.  Now,  however,  he 
is  strictly  a  clinical  man.  He  gives  you  the  practical,  daily  application  of  that 
information  he  gleaned  at  first  hand  in  the  laboratory — facts  you  can  use  in 
yiuir  bedside  practice.  Because  of  this  early  laboratory  training  you  are 
assured  that  his  book  is  correct  according  to  laboratory  standards.  Being 
now  a  strictly  clinical  man,  you  know  that  his  book  is  modeled  with  the  common 
purpose  of  all  medical  practice  :  The  treatment  of  the  sick. 


SAUNDERS'    BOOKS    ON 


Musser    and    Kelly    on 
Treatment 


A  Handbook  of  Practical  Treatment.  By  82  eminent 
specialists.  Edited  by  JOHN  H.  MUSSER,  M.  D.,  and  A  .O.  J. 
KELLY,  M.  D.,  University  of  Pennsylvania.  Three  octavo  vol- 
umes, averaging  950  pages  each,  illustrated.  Per  volume  :  Cloth, 
$6.00  net;  Half  Morocco,  $7.50  net. 

THE  TREATMENT  THAT  IS  ALL  TREATMENT 

Every  chapter  in  this  work  was  written  by  a  specialist  of  unquestioned 
authority.  Not  only  is  drug  therapy  given,  but  also  dietotherapy,  serumtherapy, 
organotherapy,  rest-cure,  exercise  and  massage,  hydrotherapy,  climatology, 
electrotherapy,  .*--ray,  and  radial  activity  are  fully,  clearly,  and  definitely 
discussed.  Those  measures  partaldng  of  a  surgical  nature  have  been  pre- 
sented by  surgeons. 

The  Medical  Record 

"  The  most  modern  and  advanced  views  are  presented.  It  is  difficult  to  pick  out  any 
one  topic  that  deserves  special  commendation,  all  parts  fully  covering  their  particular  field, 
and  written  with  that  fulness  of  detail  demanded  by  the  every-day  needs  of  the  practitioner." 


Thomson's  Clinical  Medicine 

Clinical  Medicine.  By  WILLIAM  HANNA  THOMSON,  M.D., 
LL.  D.,  formerly  Professor  of  the  Practice  of  Medicine  and  of 
Diseases  of  the  Nervous  System,  New  York  University  Medical 
College.  Octavo  of  667  pages.  Cloth,  $5.00  net;  Half  Moroc- 
co, $6.50  net. 

JUST  READY 

This  new  work  represents  over  a  half  century  of  active  practice  and  teach- 
ing. It  deals  with  bedside  medicine  —  the  application  of  medical  knowledge 
for  the  relief  of  the  sick.  First  the  meaning  of  common  and  important  symp- 
toms is  stated  definitely  ;  then  follows  a  chapter  on  the  use  of  remedies  and 
a  classification  of  them  ;  next  the  section  on  infections,  and  last  a  section  on 
diseases  of  particular  organs  and  tissues.  An  important  chapter  is  that  on  the 
mechanism  of  surface  chill  and  "catching  cold,"  going  very  clearly  into  the 
etiologic  factors,  and  outlining  the  treatment.  The  chapter  on  remedies  takes 
up  non-medicinal  and  medicinal  remedies  and  vaccine  and  serum  therapy. 
The  infectious  diseases  are  taken  up  in  Part  II,  while  Part  III  deals  with 
diseases  of  special  organs  or  tissues,  every  disease  being  fully  presented  from 
the  clinical  side. 


DIAGNOSIS  AND    TREATMENT 


Cabot's  Differential  Diagnosis 

Differential  Diagnosis.  Presented  through  an  analysis  of 
385  Cases.  By  RICHARD  C.  CABOT,  M.D.,  Assistant  Professor  of 
Clinical  Medicine,  Harvard  Medical  School,  Boston.  Octavo  of 
764  pages,  illustrated.  Cloth,  $5.50  net. 

SECOND   EDITION 

Dr.  Cabot's  work  takes  up  diagnosis  from  the  point  of  view  of  the/r^- 
lenting  symptom — the  symptom  in  any  disease  which  holds  the  foreground  in 
the  clinical  picture  :  the  principal  complaint.  It  groups  diseases  under  these 
symptoms,  and  works  backward  from  them  to  the  diseases  behind  them. 

Chas.  Lyman  Greene.  M.  D.,  University  of  Minnesota 

"  It  is  one  of  the  most  valuable  books  that  has  been  published  in  recent  years  or,  indeed, 
at  any  tinia." 


Morrow's  Diagnostic  and 
Therapeutic   Technic 

Diagnostic  and  Therapeutic  Technic.  By  ALBERT  S. 
MORROW,  M. D..  Adjunct  Professor  of  Surgery,  New  York  Poly- 
clinic.  Octavo  of  775  pages,  with  815  original  line  drawings. 
Cloth,  $5.00  net. 

JUST  THE  WORK  FOR  PRACTITIONERS 

Dr.  Morrow's  new  work  is  decidedly  a  work  for  you — the  physician  en- 
gaged in  general  practice.  It  is  a  work  you  need  because  it  tells  you  just 
how  to  perform  those  procedures  required  of  you  even'  day,  and  it  tells  you 
and  shows  you  by  clear,  nnu  line-drawings,  in  a  way  never  before  approached. 
The  information  it  gives  is  such  as  you  need  to  know  every  day — transfusion 
and  infusion,  hypodermic  medication,  Bier's  hyperemia,  exploratory  punc- 
tures, aspirations,  anesthesia,  etc. 

Journal  American  Medical  Association 

"  The  procedures  described  are  those  which  practitioners  may  at  some  time  be  called 
on  to  perform." 


SAUNDERS'    BOOKS    ON 


Faught's   Blood-Pressure 

Blood-Pressure   from    the    Clinical    Standpoint.      By 

FRANCIS  A.  FAUGHT,  M.  D. ,  formerly  Director  of  the  Laboratory 
of  Clinical  Medicine  of  the  Medico-Ch'rurgical  College  of  Phila- 
delphia. Octavo  of  281  pages,  illustrated.  Cloth,  $3.00  net. 

THREE  PRINTINGS  IN  SIX  MONTHS 

Dr.  Faught's  book  is  designed  for  practical  help  at  the  bedside.  It  meets 
the  urgent  needs  of  the  general  practitioner,  who  heretofore  had  no  book  to 
which  to  turn  in  case  of  emergency.  Every  effort  has  been  made  to  provide 
here  a  practical  guide,  full  of  information  of  a  clinical  nature,  and  presented 
in  a  way  readily  available  for  daily  use  by  the  busy  man.  Besides  the  actual 
technic  of  using  the  sphygmomanometer  in  diagnosing  disease,  Dr.  Faught 
has  included  a  brief  general  discussion  of  the  process  of  circulation.  The 
practical  application  of  sphygmomanometric  findings  within  recent  years  makes 
it  imperative  for  every  medical  man  to  have  close  at  hand  an  up-to-date  work 
on  this  subject 

Anders  and  Boston's  Medical 

Diagnosis 

A  Text-Book  of  Medical  Diagnosis.  By  JAMES  M.  AN- 
DERS, M.D.,  PH.D.,  LL.  D.,  Professor  of  the  Theory  and  Prac- 
tice of  Medicine  and  of  Clinical  Medicine,  and  L.  NAPOLEON 
BOSTON,  M.D.,  Adjunct  Professor  of  Medicine,  Medico-Chirur- 
gical  College,  Philadelphia.  Octavo  of  1175  pages,  with  443 
illustrations.  Cloth,  $6.00  net. 

THE  MODERN  DIAGNOSIS 

This  new  work  is  designed  expressly  for  the  general  practitioner.  The 
methods  given  are  practical  and  especially  adapted  for  quick  reference.  The 
diagnostic  methods  are  presented  in  a  forceful,  definite  Way  by  men  who  have 
had  wide  experience  at  the  bedside  and  in  the  clinical  laboratory. 

The  Medical  Record 

"  The  association  in  its  authorship  of  a  celebrated  clinician  and  a  well-known  labora- 
tory worker  is  most  fortunate.  It  must  long  occupy  a  pre-eminent  position." 


PRACTICE  OF  MEDICINE 


Ward's    Bedside    Hematology 

Bedside  Hematology.  By  GORDON  R.  WARD,  M.  D., 
Fellow  of  the  Royal  Society  of  Medicine,  London,  England. 
Octavo  of  394  pages,  illustrated.  Cloth,  $3.50  net. 

JUST  OUT— INCLUDING  VACCINES  AND  SERUMS 

Dr.  Ward's  work  is  designed  to  be  of  service  to  the  man  in  general  prac- 
tice. It  gives  you  the  exact  technic  for  obtaining  the  blood  for  examination, 
the  making  of  smears,  making  the  blood-count,  finding  coagulation  time,  etc. 
Then  it  takes  up  each  disease,  giving  you  the  general  pathology,  etiology, 
bearings  of  age  and  sex,  onset,  symptomatology,  course,  clinical  varieties, 
complications,  diagnosis,  and  treatment  (drug,  diet,  rest,  vaccines  and  serums, 
jr-ray,  operations,  etc.).  There  is  a  special  chapter  devoted  to  the  medical 
treatment  of  hemorrhage,  giving  you  the  exact  doses  of  the  various  drugs  in- 
dicated and  the  methods  of  their  administration,  the  serum  treatment,  trans- 
fusion, etc.  Another  chapter  is  devoted  to  the  value  of  blood  findings  in 
surgical  diagnosis,  pointing  out  their  value  in  differentiating  benign  from 
malignant  growths,  infectious  from  other  diseases,  appendicitis  from  typhoid 
fever. 

Smith's  What  to  Eat  £»  Why 

What  to  Eat  and  Why.  By  G.  CARROLL  SMITH,  M.D., 
Boston.  1 2mo  of  312  pages.  Cloth,  $2.50  net. 

FOR  THE  PRACTITIONER 

With  this  book  you  no  longer  need  send  your  patients  to  a  specialist  to 
be  dieted — you  will  be  able  to  prescribe  the  suitable  diet  yourself,  just  as  you 
do  other  forms  of  therapy.  Dr.  Smith  gives  "the  why"  of  each  statement 
he  makes.  It  is  this  knowing  why  which  gives  you  confidence  in  the  book, 
which  makes  you  feel  that  Dr.  Smith  knows. 


Slade's  Physical  Examination  &  Diagnostic  Anatomy 

PHYSICAL  EXAMINATION  AND  DIAGNOSTIC  ANATOMY. — By  CHARLES 
B.  SLADE,  M.D.,  Chief  of  Clinic  in  General  Medicine,  University  and 
Btllevue  Hospital  Medical  College.  I2nx>  of  146  pages,  illustrated. 
Cloth,  $1.25  net. 


SAUNDEKS'  BOOKS  ON 


Garrison's  History  of  Medicine 

History  of  Medicine.  With  Medical  Chronology,  Biblio- 
graphic Data,  and  Test  Questions.  By  FIELDING  H.  GARRISON, 
M.  D.,  Principal  Assistant  Librarian,  Surgeon-General's  Office, 
Washington,  D.  C.  Octavo  of  763  pages,  illustrated.  Cloth, 
$6.00  net ;  Half  Morocco,  $7.50  net. 

THE  BAEDEKER  OF  MEDICAL  HISTORY 

The  work  begins  with  ancient  and  primitive  medicine,  and  carries  you  in 
a  most  interesting  and  instructive  way  on  through  Egyptian  medicine,  Sumerian 
and  Oriental  medicine,  (Ireek  medicine,  the  Byzantine  period;  the  Mohamme- 
dan and  Jewish  periods,  the  Medieval  period,  the  period  of  the  Renaissance, 
the  Revival  of  learning  and  the  Reformation  ;  the  Seventeenth  Century  (the 
age  of  individual  scientific  endeavor),  the  Eighteenth  Century  (the  age  of 
theories  and  systems),  the  Nineteenth  Century  (the  beginning  of  organized  ad- 
vancement of  science),  the  Twentieth  Century  (the  beginning  of  organized 
preventive  medicine).  You  get  all  the  important  facts  in  medical  history;  a 
biographic  dictionary  of  the  makers  of  medical  history,  arranged  alphabetically; 
an  album  of  medical  portraits;  a  complete  medical  chronology  (data  on  dis- 
eases, drugs,  operations,  etc.);  a  brief  survey  of  the  social  and  cultural  phases 
of  each  period. 


McKenzie  on  Exercise 

Exercise  in  Education  and  Medicine.  Bv  R.  TAIT 
MCKENZIE,  B.  A.,  M.  D. ,  Professor  of  Physical  Education,  and 
Director  of  the  Department,  University  of  Pennsylvania.  Oc- 
tavo of  406  pages,  with  346  illustrations.  Cloth,  $3.50  net. 

D.  A.  Sargent,  M.  D.,  Director  of  Hemenway  Gymnasium,  Harvard  University. 

"  It  cannot  fail  to  be  helpful  to  practitioners  in  medicine.  The  classification  of  athletic 
games  and  exercises  in  tabular  form  for  different  ages,  sexes,  and  occupations  is  the  work  of 
an  expert.  It  should  be  in  the  hands  of  every  physical  educator  and  medical  practitioner." 


Carter's  Diet  Lists 

DIET  LISTS  OF  THE  PRESBYTERIAN  HOSPITAL  OF  NEW  YORK  CITY. 
Compiled,  with  notes,  by  HERBERT  S.  CARTER,  M.  D.  I2mo  of  129 
pages.  Cloth,  $1.00  net. 

Bonney's  Tuberculosis  second  Edition 

TUBERCULOSIS.  By  SHERMAN  G.  BONNEY,  M.D.,  Professor  of 
Medicine,  Denver  and  Gross  College  of  Medicine.  Octavo  of  955  pages, 
with  243  illustrations.  Cloth,  f  7.00  net ;  Half  Morocco,  $8.50  net. 


THE    PRACTICE    OF   MEDICINE 


Anders* 
Practice    of    Medicine 

A  Text-Book  of  the  Practice  of  Medicine.  By  JAMES 
M.  ANDERS,  M.  D.,  PH.  D.,  LL.  D.,  Professor  of  the  Practice 
of  Medicine  and  of  Clinical  Medicine,  Medico-Chirurgical  Col- 
lege, Philadelphia.  Handsome  octavo,  1332  pages,  fully  illus- 
trated. Cloth,  $5.50  net ;  Half  Morocco,  $7.00  net. 

NEW  (llth)  EDITION 

The  success  of  this  work  is  no  doubt  due  to  the  exteasive  consideration 
given  to  Diagnosis  and  Treatment,  under  Differential  Diagnosis  the  points  of 
distinction  of  simulating  diseases  being  presented  in  tabular  form.  In  this 
new  edition  Dr.  Anders  has  included  all  the  most  important  advances  in 
medicine,  keeping  the  l>ook  within  bounds  by  a  judicious  elimination  of 
obsolete  matter.  A  great  many  articles  have  also  been  rewritten. 

Wm.  E.  Qtrine,  M.  D.,   College  of  Physicians  and  Surgeons,  Chicago. 

"  1  consider  Anders'  Practice  one  of  the  best  single-volume  works  before  the  profession 
at  this  time,  and  one  of  the  best  text-books  for  medical  students." 


DaCosta's   Physical  Diagnosis 

Physical  Diagnosis.  By  JOHN  C.  DACOSTA,  JR.,  Asso- 
ciate Professor  of  Medicine,  Jefferson  Medical  College.  Octavo 
of  557  pages,  with  original  illustrations.  Cloth,  $3.50  net. 

SECOND  EDITION 

In  Dr.  DaCosta's  work  every  method  given  has  been  carefully  tested  and 
proved  of  value  by  the  author  himself.  Normal  physical  signs  are  explained 
in  detail  in  order  to  aid  the  diagnostician  in  determining  the  abnormal.  Both 
direct  and  differential  diagnoses  are  emphasized.  The  212  original  illustra- 
tions are  artistic  as  well  as  practical. 

Henry  L.  Eisner,   M.  D.,   Professor  of  Medicine,  Syracuse  University. 

"  I  have  reviewed  this  book  and  am  thoroughly  convinced  that  it  is  one  of  the  best 
ever  written  on  the  subject.  In  every  way  I  find-it  a  superior  production." 


Sahli's  Diagnostic  Methods 

Edited  by  Nath'l  Bowditch  Potter,   M.D. 


A  Treatise  on  Diagnostic  Methods  of   Examination. 

By  PROF.  DR.  H.  SAHLI,  of  Bern.  Edited,  with  additions,  by 
NATH'L  BOWDITCH  POTTER,  M.D.,  Assistant  Professor  of  Clinical 
Medicine,  Columbia  University.  Octavo  of  1225  pages,  pro- 
fusely illustrated.  Cloth,  $6.50  net. 

SECOND  EDITION,  RESET 

Lewellys  F.  Barker,  M.  D. 

Professor  of  Medicine,  Johns  Hopkins  University 

"  I  am  delighted  with  it,  and  it  will  be  a  pleasure  to  recommend  it  to  our  students  in 
the  Johns  Hopkins  Medical  School." 


Friedenwald  &  Ruhrah  on  Diet 

Diet  in  Health  and  Disease.  By  JULIUS  FRIEDENWALD, 
M.  D.,  Professor  of  Diseases  of  the  Stomach,  and  JOHN  RUHRAH, 
M.  D.,  Professor  of  Diseases  of  Children,  College  of  Physicians 
and  Surgeons,  Baltimore.  Octavo  of  85  7  pages.  Cloth,  $4.00  net. 

JUST  READY— NEW  (4th)  EDITION 

Dietetic  management  in  all  diseases  in  which  diet  plays  a  part  in  treat- 
ment is  carefully  considered,  the  articles  on  diet  in  diseases  of  the  digestive 
organs  containing  numerous  diet  lists  and  explicit  instructions  for  administra- 
tion. The  feeding  of  infants  and  children,  of  patients  before  and  after  anes- 
thesia and  surgical  operations,  are  all  taken  up  in  detail. 

"  It  seems  to  me  that  you  have  prepared  the  most  valuable  work  of  the  kind  now  avail- 
able. I  am  especially  glad  to  see  the  long  list  of  analyses  of  different  kinds  of  food." — 
GEORGE  DOCK,  M.  D.,  Tulane  University  of  Louisiana. 


Eggleston's  Prescription  Writing 

This  new  work  is  a  crystallization  of  Dr.  Eggleston's  long  experience 
in  teaching  this  subject.  It  covers  the  entire  field  in  a  most  practical  way, 
taking  up  grammar,  construction,  dosage,  vehicles,  incompatibility,  ad- 
ministration, etc. 

i6mo  of  115  pages.     By  GARY  EGGLESTON,  M.  D.,  Instructor  in  Pharmacology  at 
Cornell  University  Medical  School.     Cloth   $1.00  net.  i 


PRACTICE  OF  MEDICINE 


Kemp  on  Stomach, 
Intestines,  and  Pancreas 

Diseases  of   the   Stomach,   Intestines,    and    Pancreas. 

By  ROBERT  COLEMAN  KEMP,  M.  D.,  Professor  of  Gastro-intes- 
tinal  Diseases  at  the  New  York  School  of  Clinical  Medicine. 
Octavo  of  1025  pages,  with  377  illustrations.  Cloth,  $6.50  net; 
Half  Morocco,  $8.00  net. 

NEW  (26)  EDITION 

It  is  the  practitioner  who  first  meets  with  these  cases,  and  it  is  he  upon 
whom  the  burden  of  diagnosis  rests.  After  the  diagnosis  is  established,  the 
practitioner,  if  properly  equipped,  could  frequently  treat  the  case  himself 
instead  of  transferring  it  to  a  specialist.  This  work  is  intended  to  equip  the 
practitioner  with  this  end  in  view. 

The  Therapeutic  Gazette 

"  The  therapeutic  advice  which  is  given  is  excellent.  Methods  of  physical  and 
chemical  examination  are  adequately  and  correctly  described." 


Deaderick  on  Malaria 


Practical  Study  of  Malaria.  By  WILLIAM  H.  DEADERICK, 
M.  D.,  Member  American  Society  of  Tropical  Medicine. 
Octavo  of  402  pages,  illustrated.  Cloth,  $4.50  net; 

Frank  A.  Jones,  M.  D.,  Memphis  Hospital  Mtdical  College. 

"  Dr.  Deaderick's  book  is  up  to  date  and  the  subject  matter  is  well  arranged.  We 
have  been  waiting  for  many  years  for  such  a  work  written  by  a  man  who  sees  malaria  in 
all  its  forms  in  a  highly  malarious  climate." 


Niles  on  Pellagra 

Pellagra.  By  GEORGE  M.  NILES,  M.  D.,  Professor  of  Gastro- 
enterology  and  Therapeutics,  Atlanta  School  of  Medicine.  Oc- 
tavo of  253  pages,  illustrated.  Cloth,  $3.00  net. 

This  is  a  book  you  must  have  to  get  in  touch  with  the  latest  advances  con- 
cerning this  disease.  It  is  the  first  book  on  the  subject  by  an  American 
author,  and  the  first  in  any  language  adequately  covering  diagnosis  and 
treatment. 


io  SAUNDERS'    BOOKS    OiV 

AMERICAN  EDITION 

NOTHNAGEL'S    PRACTICE 

UNDER   THE   EDITORIAL   SUPERVISION   OF 

ALFRED    STENGEL,    M.D. 

Professor  of  Medicine  in  the  University  of  Pennsylvania 


Typhoid  and  Typhus  Fevers 

By  DR.  H.  CURSCHMANN,  of  Leipsic.  Edited,  with  additions,  by 
WILLIAM  OSLER,  M.  D.,  F.  R.  C.  P.,  Oxford  University,  Oxford, 
England.  Octavo  of  646  pages,  illustrated. 

Smallpox  (including  Vaccination),  Varicella,  Cholera 
Asiatica,  Cholera  Nostras,  Erysipelas,  Erysip- 
eloid,  Pertussis,  and  Hay  Fever 

By  DR.  H.  IMMERMANN,  of  Basle  ;  DR.  TH.  VON  JURGENSEN,  of 
Tubingen ;  DR.  C.  LIEBERMEISTER,  of  Tubingen ;  DR.  H.  LENHARTZ, 
of  Hamburg ;  and  DR.  G.  STICKER,  of  Giessen.  The  entire  volume 
edited,  with  additions,  by  SIR  J.  W.  MOORE,  M.  D.,  F.  R.  C.  P.  I., 
Royal  College  of  Surgeons,  Ireland.  Octavo  of  682  pages,  illustrated. 

Diphtheria,  Measles,  Scarlet  Fever,  and  Rotheln 

By  WILLIAM  P.  NORTHRUP,  M.  D.,  of  New  York,  and  DR.  TH. 
VON  JURGENSEN,  of  Tubingen.  The  entire  volume  edited,  with  additions, 
by  WILLIAM  P.  NORTHRUP,  M.  D.,  University  and  Bellevue  Hospital 
Medical  College.  Octavo  of  672  pages,  illustrated. 

Diseases  of  the  Bronchi,  Diseases  of  the  Pleura,  and 
Inflammations  of  the  Lungs 

By  DR.  F.  A.  HOFFMANN,  of  Leipsic;  DR.  O.  ROSENBACH,  of 
Berlin ;  and  DR.  F.  AUFRKCHT,  of  Magdeburg.  The  entire  volume 
edited,  with  additions,  by  JOHN  H.  MUSSER,  M.  D.,  University  of  Penn- 
sylvania. Octavo  of  1029  pages,  illustrated. 

Diseases  of  the  Pancreas,  Suprarenals,  and  Liver 

By  DR.  L.  OSER,  of  Vienna;  DR.  E  NUSSER.  of  Vienna:  and  DRS. 
H.  QUINCKE  and  G.  HOPPE-SEYI.ER,  of  Kiel.  The  entire  volume 
edited,  with  additions,  by  REGINALD  H.  FITZ,  A.  M.,  M.  D.,  Harvard 
University;  and  FREDERICK  A.  PACKARD,  M.  D.,  Pennsylvania  and 
Children's  Hospitals,  Philadelphia.  Octavo  of  918  pages,  illustrated. 

PER  VOLUME:   CLOTH,  $5.00  NET;    HALF  MOROCCO,   $6.00  NET 


PRACTICE    OF  ME  DIC I XE  U 

AMERICAN    EDITION 

NOTHNAGEL'S    PRACTICE 

Diseases  of  the  Stomach 

By  DR.  F.  RII.GKL,  of  Giessen.  Edited,  with  additions,  by  CHARLES 
G.  STOCK  ION,  M.  D.,  University  of  Buffalo.  Octavo  of  835  pages. 

Diseases  of  the  Intestines  and  Peritoneum        Edition 

By  DR.  HKKMANN  N<»THN.-U;I-:L,  of  Vienna.  Edited,  with  additions, 
by  H.  D.  ROLI.ESTON,  M.  D.,  F.  R.  C.  P.,  St.  George's  Hospital, 
London.  Octavo  of  1 100  pages,  illustrated. 

Tuberculosis  and  Acute  General  Miliary  Tuberculosis 

By  DR.  G.  CORNET,  of  Berlin.  Edited,  with  additions,  by  WALTER 
B.  JAMES,  M.  D.,  Columbia  University,  New  York.  Octavo  of  806  pages. 

Diseases  Of  Blood  {Anemia,  Chlorosis,  Leukemia,  Pseudoleukemia') 

By  DR.  P.  EHRLICH,  of  Frankfort-on-the-Main ;  DR.  A.  LAZARUS,  of 
Charlottenburg  ;  DR.  K.  VON  NOORDEN,  of  Frankfort-on-the-Main;  and 
DR.  FELIX  PINKUS,  of  Berlin.  The  entire  volume  edited,  with  addi- 
tions, by  ALFRED  STENGEL,  M.  I).,  University  of  Pennsylvania.  Octavo 
of  714  pages,  illustrated. 

Malaria,  Influenza,  and  Dengue 

By  DR.  J.  MANNABERG,  of  Vienna,  and  DR.  O.  LEICHTENSTERN,  of 
Cologne.  The  entire  volume  edited,  with  additions,  by  RONALD  Ross, 
F.  R.  C.  S.,  University  of  Liverpool;  J.  W.  W.  STEPHENS,  M.  D., 
D.  P.  H.,  University  of  Liverpool  ;  and  ALBERT  S.  GRUNBAUM,  F. 
R.  C.  P.,  University  of  Liverpool.  Octavo  of  769  pages,  illustrated. 

Kidneys,  Spleen,  and  Hemorrhagic  Diatheses 

By  DR.  H.  SENATOR,  of  Berlin,  and  DR.  M.  LITTEN,  of  Berlin.  The 
entire  volume  edited,  with  additions,  by  JAMES  B.  HERRICK,  M.  D., 
Rush  Medical  College.  Octavo  of  815  pages,  illustrated. 

Diseases  of  the  Heart 

By  PROF.  DR.  TH.  VON  JGRGENSEN,  of  Tubingen ;  PROF.  DR.  L. 
KREHL,  of  Griefswald;  and  PROF.  DR.  L.  VON  SCHROTTER,  of 
Vienna.  The  entire  volume  edited,  with  additions,  by  GEORGE  DOCK, 
M.  D.,  Tulane  University  of  Louisiana.  Octavo  of  848  pages. 

PER  VOLUME:  CLOTH,  $5.00  NET;  HALF  MOROCCO,  $6.00  NET 


Goepp's  State  Board  Questions  Third  Edition 

STATE  BOARD  QUESTIONS  AND  ANSWERS.  By  R.  MAX  GOEPP, 
M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  Octavo 
of  715  pages.  Cloth,  {4.00  net 

"  Nothing  has  been  printed  which  is  so  admirably  adapted  as  a  guide  and  self-quiz 
for  those  intending  to  take  State  Board  Examinations." — Pennsylvania  Medical 
Journal 


SAUNDERS1    BOOKS  ON 


Stevens'  Therapeutics  Fifth  Edition 

A  TEXT-BOOK  OF  MODERN  MATERIA  MEDICA  AND  THERAPEUTICS. 
By  A.  A.  STEVENS,  A.M.,  M.D.,  Lecturer  on  Physical  Diagnosis  in  the 
University  of  Pennsylvania.  Octavo  of  675  pages.  Cloth,  $3.50  net. 

Dr.  Stevens'  Therapeutics  is  one  of  the  most  successful  works  on  the  subject  ever 
published.  In  this  new  edition  the  work  has  undergone  a  very  thorough  revision, 
and  now  represents  the  very  latest  advances. 

The  Medical  Record,  New  York 

"  Among  the  numerous  treatises  on  this  most  important  branch  of  medical  practice, 
this  by  Dr.  Stevens  has  ranked  with  the  best." 

Butler's  Materia  Medica  Sixth  Edition 

A  TEXT-BOOK  OF  MATERIA  MEDICA,  THERAPEUTICS,  AND  PHARMA- 
COLOGY. By  GEORGE  F.  BUTLER,  Pn.G.,  M.D.,  Professor  and  Head 
of  the  Department  of  Therapeutics  and  Professor  of  Preventive  and 
Clinical  Medicine,  Chicago  College  of  Medicine  and  Surgery,  Medical 
Department  Valpariso  University.  Octavo  of  702  pages,  illustrated. 
Cloth,  $4.00  net ;  Half  Morocco,  $5.50  net. 

For  this  sixth  edition  Dr.  Butler  has  entirely  remodeled  his  work,  a  great  part  hav- 
ing been  rewritten.  All  obsolete  matter  has  been  eliminated,  and  special  attention 
has  been  given  to  the  toxicologic  and  therapeutic  effects  of  the  newer  compounds. 

Medical  Record,  New  York 

"  Nothing  has  been  omitted  by  the  author  which,  in  his  judgment,  would  add  to 
the  completeness  of  the  text." 

Sollmann's  Pharmacology  Second  Edition 

A  TEXT-BOOK  OF  PHARMACOLOGY.  By  TORALD  SOLI.MANX,  M.D., 
Professor  of  Pharmacology  and  Materia  Medica,  Western  Reserve  Uni- 
versity. Octavo  of  1070  pages,  illustrated.  Cloth,  $4.00  net. 

The  author  bases  the  study  of  therapeutics  on  systematic  knowledge  of  the  nature 
and  properties  of  drugs,  and  thus  brings  out  forcibly  the  intimate  relation  between 
pharmacology  and  practical  medicine. 

J.  F.  Fotheringham,  M.D.,  Trinity  Medical  College,   Toronto. 

"  The  work  certainly  occupies  ground  not  covered  in  so  concise,  useful,  and  scien- 
tific a  manner  by  any  other  text  I  have  read  on  the  subjects  embraced." 

Arny's  Pharmacy 

PRINCIPLES  OF  PHARMACY.  By  HENRY  V.  ARNY,  PH.  G.,  PH.  D., 
Professor  of  Pharmacy,  New  York  College  of  Pharmacy.  Octavo  of 
1175  pages,  with  246  illustrations.  Cloth.  $5.00  net. 

George  Reimann,  Ph.  G.,  Secretary  of  the  New  York  State  Board  of  Pharmacy . 

"  I  would  say  that  the  book  is  certainly  a  great  help  to  the  student,  and  I  think  it 
ought  to  be  in  the  hands  of  every  person  who  is  contemplating  the  study  of  pharmacy.1' 


THERAPEUTICS  AND  MATERlA  MED  1C  A  13 


Hinsdale's   Hydrotherapy 

Hydrotherapy  :  A  Treatise  on  Hydrotherapy  in  General ; 
Its  Application  to  Special  Affections ;  the  Technic  or  Processes 
Employed,  and  the  Use  of  Waters  Internally.  By  GUY  HINSDALE, 
M.  D.,  Fellow  of  the  Royal  Society  of  Medicine  of  Great  Britain. 
Octavo  of  466  pages,  illustrated.  Cloth, $3. 50  net. 


The  Medical  Record 

"  We  cannot  conceive  of  a  work  more  useful  to  the  general  practitioner  than  this,  no 
one  to  which  he  would  resort  more  frequently  for  reference  and  guidance  in  his  dail 
work." 


Kelly's  Cyclopedia  of  American 
Medical  Biography 

Cyclopedia  of  American  Medical  Biography.  By  HOW- 
ARD A.  KELLY,  M.  D.,  Johns  Hopkins  University.  Two  octavos 
of  525  pages  each,  with  portraits.  Per  set :  Cloth,  $10.00  net; 
Half  Morocco,  $13.00  net. 

Dr.  Kelly,  in  these  two  handsome  volumes,  presents  concise,  yet  com- 
plete biographies  of  those  men  and  women  who  have  contributed  notewor- 
thily  to  the  advancement  of  medicine  in  America.  Dr.  Kelly's  reputation  for 
painstaking  care  assures  accuracy  of  statement.  There  are  about  one  thousand 
biographies  included. 

Swan's  Prescription-writing  and  Formulary 

PRESCRIPTION-WRITING  AND  FORMULARY.  By  JOHN  M.  SWAN, 
M.D.,  Director  Glen  Springs  Sanitarium,  \Vatkins,  N.  Y.  I2mo  of  185 
pages.  Flexible  cloth,  $1.25  net. 

Stewart's    Pocket    Therapeutics    and    Dose- 
book  New  (4th)  Edition 

POCKET  THERAPEUTICS  AND  DOSE-BOOK.  By  MORSE  STEWART,  JR., 
M.  D.  32mo  of  263  pages.  Cloth,  $1.00  net. 

Bohm  and  Painter's  Massage 

MASSAGE.  By  MAX  BOHM,  M.  D.,  of  Berlin,  Germany.  Edited, 
with  an  Introduction,  by  CHARLES  F.  PAINTER,  M.  D.,  Professor  of 
Orthopedic  Surgery  at  Tufts  College  Medical  School,  Boston.  Octavo 
of  91  pages,  with  ^practical  illustrations.  Cloth,  $1-75  net. 


14  SAUNDERS*    BOOKS   ON 

GET  Am<*r«i"an  THE  NEW 

THE  BEST  nmencan  STANDARD 

Illustrated   Dictionary 

The  New  (7th)  Edition,  Reset 

The  American  Illustrated  Medical  Dictionary.     By  W.  A. 

NEWMAN  BORLAND,  M.  D.,  Editor  of  "The  American  Pocket 
Medical  Dictionary."  Octavo  of  1107  pages.  Flexible  leather, 
$4.50  net;  with  thumb  index,  $5.00  net. 

OVER  5000  NEW  WORDS 

Howard   A.    Kelly,    M.  D.»  Johns  Hopkins  University,  Baltimore. 

"  Dr.  Dorland's  dictionary  is  admirable.      It  is  so  well  gotten  up  and  of  such  conve- 
nient size.     No  errors  have  been  found  in  my  use  of  it." 


Thornton's  Dose-Book  Fourth  Edition 

DOSE-BOOK    AND    MANUAL    OF     Pkl  SCRIPTK  >N-\YKITING.       By    E.    Q. 

THORNTON,  M.  D.,  Assistant  Professor  of  Materia  Medica,  Jefferson 
Medical  College,  Philadelphia.  Post-octavo,  392  pnges,  illustrated. 
Flexible  leather,  $2.00  net. 


Lusk    On    Nutrition  Second  Edition 

ELEMENTS  OF  THE  SCIENCE  OF  NUTRITION.  By  GRAHAM  LUSK, 
PH.D.,  Professor  of  Physiology  in  Cornell  University  Medical  School. 
Octavo  of  402  pages.  Cloth,  $3.00  net. 

"  I  shall  recommend  it  highly.  It  is  a  comfort  to  have  such  a  discussion  of  the 
subject." — LKWBLLYS  F.  BARKER,  M.  D.,  Professor  of  the  Principles  and  Practice 
of  Medicine,  Johns  Hopkins  University. 

Hatcher  and  Sollmann's  Materia  Medica 

A  TEXT- BOOK  OF  MATKRIA  MEDICA:  including  Laboratory  Exer- 
cises in  the  Histologic  and  Chemic  Examination  of  Drugs.  By  ROBERT 
A.  HATCHER,  PH.  G.,  M.  D. ;  and  TORALD  SOI.LMANN,  M.  D.  i2mo 
of  411  pages.  Flexible  leather,  $200  net. 

Bridge  on  Tuberculosis 

TUBERCULOSIS.  By  NORMAN  BRIDGE,  A.  M.,  M.  D.  I2mo  of  302 
pages,  illustrated.  Cloth,  $1 .50  net. 


MATER  I  A  ME  DIG  A  AND   THERAPEUTICS.  15 


New 


American  Pocket  Dictionary 

THE  AMERICAN  POCKET  MEDICAL  DICTIONARY.  Edited  by  \\  . 
A  \K\VMAN  BORLAND,  M.D.  Flexible  leather,  with  gold  edges,  $1.00 
net  ;  with  thumb  index,  $1.25  net. 

Pusey  and  Caldwell  on  X-Rays  Second  Edition 

THE  PRACTICAL  APPLICATION  OF  THE  RONTGEN  RAYS  IN  THERA- 
PEUTICS AND  DIAGNOSIS.  By  WILLIAM  ALLEN  PUSEY,  A.  M.,  M.  D., 
and  EUGENE  W.  CALDWELL,  B.  S.  Octavo  of  625  pages,  with  200 
illustrations.  Cloth,  $5.00  net. 

Cohen  and  Eshner's  Diagnosis.    Second  Revised  Edition 

ESSENTIALS  OF  DIAGNOSIS.  By  S.  SOLIS-COHEN,  M.  D.,  and  A.  A. 
ESHNER,  M.  D.  Post-octavo,  382  pages;  55  illustrations.  Cloth,  $1.00 
net.  In  Satin  Jers1  Question-  Compend  Series. 

Seventh 

Morris'  Materia  Medica  and  Therapeutics         Edition 

ESSENTIALS  OF  MATERIA  MEDICA,  THERAPEUTICS,  AND  PRESCRIP- 
TION-WRITING. By  HENRY  MORRIS,  M.D.  Revised  by  \V.  A.  BAS- 
TEDO,  M.  D.,  Instructor  in  Materia  Medica  and  Pharmacology,  Columbia 
University.  1  2mo,  300  pages.  Cloth,  $  1  .00  net.  Sanntieri  Compends, 

Williams'  Practice  of  Medicine 

ESSENTIALS  OF  THE  PRACTICE  OF  MEDICINE.  By  W.  R.  WILLIAMS, 
M.D.,  formerly  Lecturer  on  Hygiene  and  Instructor  in  Medicine,  Cornell 
University,  N.  Y.  I2mo  of  460  pages.  Double  number,  £1.75  net.  In 
Sounders'  Question-  Compend  Series. 

Barton  and  Wells'  Thesaurus 

A  THESAURUS  OF  MEDICAL  WORDS  AND  PHRASES.  By  WILFRED  M. 
BARTON,  M.  D.,  and  WALTER  A.  WELLS,  M.  D.  I2mo  of  534  pages. 
Flexible  leather,  #2.50  net  ;  with  thumb  index,  #3.00  net. 

Tousey's  Medical  Electricity 

MEDICAL  ELECTRICITY  AND  THE  ARRAYS.  By  SINCLAIR  TOUSEY, 
M.  D.,  Consulting  Surgeon  to  St.  Bartholomew's  Hosoital,  New  York. 

Boston's  Clinical  Diagnosis  Second  Edition 

CLINICAL  DIAGNOSIS.  By  Laboratory  Methods.  By  L.  NAPOLEON 
BOSTON,  A.  M.,  M.  D.,  Adjunct  Professor  of  Medicine.  Medico- 
Chirurgical  College,  Philadelphia.  Octavo  of  563  pages,  with  330  illus- 
trations, many  in  colors.  Cloth,  $4.00  net. 

Arnold's  Medical  Diet  Charts 

MKDICAL  DIET  CHARTS.  Prepared  by  H.  D.  ARNOLD,  M.  D., 
Professor  of  Clinical  Medicine,  Tufts  Medical  College,  Boston.  Single 
charts,  5  cents;  50  charts,  $2.00  net;  500  charts,  #18.00  net;  looo 
charts,  $30.00  net. 


1 6  SAUJVDERS'    BOOKS    ON   PRACTICE,   Etc. 


Saunders'   Pocket   Formulary  Ninth  Edition 

SAUNDERS'  POCKET  MEDICAL  FORMULARY.  By  WILLIAM  M. 
POWELL,  M.  D.  Containing  1900  formulas  from  the  best-known 
authorities.  In  flexible  leather,  with  side  index,  wallet,  and  flap. 
$1.75  net. 

Jakob  and  Eshner's  Internal  Medicine  and  Diagnosis 

ATLAS  AND  EPITOME  OK  INTERNAL  MEDICINE  AND  CLINICAL  DIAG- 
NOSIS. By  DR.  CHR.  JAKOB,  of  Erlangen.  Edited,  with  additions,  by 
A.  A.  ESHNER,  M.  D.  182  colored  figures  on  68  plates,  64  text-cuts, 
259  pages  of  text.  Cloth,  $3.00  net.  In  Sounders'  Hand-Atlas  Series. 

Lockwood's  Practice  of  Medicine    Revisefeacn0dndEnlda^2 

A  MANUAL  OF  THE  PRACTICE  OF  MEDICINE.  By  GEO.  ROE  LOCK- 
WOOD,  M.  D.,  Attending  Physician  to  the  Bellevue  Hospital,  New  York 
City.  Octavo,  847  pages,  illustrated.  Cloth,  $4.00  net. 

Fenwick's  Dyspepsia 

DYSPEPSIA.  By  WILLIAM  SOLTAU  FENWICK,  M.  D.,  of  London. 
Octavo  of  485  pages,  illustrated.  Cloth,  $3.00  net. 

Jelliffe's   Pharmacognosy 

AN  INTRODUCTION  TO  PHARMACOGNOSY.  By  SMITH  ELY  JELLIFFE, 
PH.  D.,  M.  D.,  Columbia  University,  New  York.  Octavo  of  265  pages, 
illustrated.  Cloth,  $2.50  net. 

Stevens'   Practice   of  Medicine  Ninth  Edition 

A  MANUAL  OF  THE  PRACTICE  OF  MEDICINE.  By  A.  A.  STEVENS, 
A.  M.,  M.  D.,  Professor  of  Therapeutics  and  Clinical  Medicine,  \Yoman'  s 
Medical  College,  Philadelphia.  lamo,  573  pages,  illustrated.  Flexible 
leather,  §2.50  net. 

Camac's  Epoch-Making  Contributions 

EPOCH-MAKING  CONTRIBUTIONS  TO  MEDICINE  AND  SURGERY.  By 
C.  N.  B.  CAMAC,  M.  D.,  of  New  York  City.  Octavo  of  450  pages, 
with  portraits.  Artistically  bound,  $4.00  net. 

Todd's  Clinical  Diagnosis  Second  Edttten 

CLINICAL  DIAGNOSIS.  By  JAMES  CAMPBELL  TODD,  M.D..  Professor 
of  Pathology,  University  of  Colorado,  Denver.  I2mo  of  455  pages, 
illustrated.  *Cloth,  $-'.25  net. 


Date  Due 


(**J  CAT.    NO.    23    233  PRINTED    IN    U.S.A. 


»,„„„„ 


WQ100 
D26lm2 


Davis,  Edward  P 

Manual  of  obstetrics. 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


